01030061 CITY OFCUPERUNO
BUILDING NPERMIT CONTRACTOR INFORMATION:
BU I LD ING ADDRESS: PERMID NO.
OWNER'S NAMF,: ^ APPLICATION SUR DATE
03/12/2001
PHONE: SANITARY NO. CONTROL NO,
397O ARCHITECT/ENGINEER: BUILDING PENMI'r INFO
❑ BLDG ELECTPLUMB MECH
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asvi LICENSEDI.CONTRACilde, sDGimsof COV
_o lhombrallinnm.tl.mhcemeaandetvro.;,mnxnrclmpter9snn,mencing Job Description
4,t:J with Scc'ion]gOD fir Division lnOhexmincas and Profcaions Cole,and mYlicenu
6I,in dial Mace and t.
5 z ¢ Lceku Clue: Llc.p TI
eu O Dem Cumrecmr
5 u.G ARCI I'TEM'S DECLA Al'1 Ck
t=O g 1 understand my plans shall h used as public rea,No FINALE D
� .!i
w a O LiccnwJ Professional
OWNER-BUILDER DECLARATION AUG 3 0 2001
tail o I, I hereby affirm dmf I an,exo.....t n..... It,Cunlrucou License Law fila the
t.7a 2 following reason.Section 911.315.Holmes.umd Mom,,ia I,Code Any dry fir county
S C� which requires a,•amid to construct.alter,im{m,ve,demolish.or repair any stmcmre
i3e� prior to itsissuance.also)requires the applicant lot such permit it)file a signed salemem
- ,hal he islicensed lmr,uamn)the pmvsmnsofdouComm<m,eLicense Lata,(Cmpter9 Sq. Ft. Floor Area BUILUINUvaluation
(commencing with Sellinn 9000)of Division 3 or the B.,ml and Professions Code)
o.r met he is mgt tborminm and tee hsi,for me:lli c m,hnn.Any dolufon 171
f Saban]Oils Ay any ap,licam for:.,rain e.hj,,s the.ppfiant ,,a civil petmhy
,if nntmorethan r.ehoodmildnua.Will). APN Number Occupancy ype
❑I,to owner of the pmpedy,or my employees with wugc,as their sole compensation.
will do the work and the ewcom is nor intended n.alfead for sale ISce.7W4. �+
Business and Pmfessi neo Cnil The Cn.mneorx Lieena Law do,,,no'apply no an r Required Inspections
lrol ofm
ppcdy Who builds fir in)pmre
vc,theon,and sum)does,such w... himself
or through his own cnq,loyecsprovid,+l mel such impmvc.uents am our intended or 101 — FOUNDATION .
uRcrel rte sale.IL however,the building n.im,imunme'is Bold within one rear of
iompldion,the uwnervM1uildm will Imre the burden uf,fiwing mat he did not build fir 1.02 — PIERS
mprove for purpose of sale.),
t71.nsnwnetnr the,m,edy... xdnslv<ly emnmcti."win.heemed omm.msnnr"o 103 — UFER
mxo-net the paoJecI(See.]11W.Be, and Profess ms C«Ie:)'I'I'll Cmtracmr's 1.04 — REBAR
mese a
and who
co dims not apply v)an owner with
amPcdy,who builds fir pursu,thio the
and whn eontmet,rte.urn pn)jects with a anntme'mr,)licensed pursuant to me 105 — ANCHOR BOLTS
Cnntmexe Licenselaw.
olm.ne,e:nwunder Sec. x&Pefor this reason 1.06 — SEWER R WATER
Dwmer Mile 202 — UNDERFLOOR 'PLUMBING'
WORKER S COMPENSAIION DECII,RATION
203 — UNDERFLOOR MECHANICAL
I hereby ancon ander penalty of perjury one of following declaration x: 204 — UNDERFLOOR FRAME
. ❑ 1 have and will maintain u Ceniticam if Consent to rill-insure for IN for s _
Cmnp,a,at.o.m. an provided x). by Seodmm Am
lm of me L:m.,. Cal . tat me 205 UNDERFLOOR INSULATION
pe'l6t lu'e of Ire work Ibr which tbia ryv nit.,.s.wed.
01 ''— ROUGH PLUMBING
❑Ihm'efic Ldlrm.Code. Worker',Cnmpenzminnle work for slikh of by Sed an 302 — TUB & OR SHOWER
37W of the)aha Cale,for he perb)munce of the work for which this,ermi'is
iwoedMyywor1k1t,"Cmnpensationm>ummemmerrandpolicynumberam: 303 — ROUGH MECHANICAL
Curti`'"Y—�[J.sr Volk,No.: LLJn� ^@4 — ROUGH ELECTRICAL
CERT IFIC''A'I ON OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 305 — FRAME
(This section need not be completed if the pc.mit is for one hundred dollars 306 — HOLDOWNS
ISIIXA fir lgexJ
I comfy that m fie Mab,nm.amo nl the work),.which his permit is ixxaea,1 307 — INSULATION
,hall on cmpiny any pe..nn in it,.u.nner on a,In Imcmne object m flet W..kers. 308 — SHEET ROCK
Compenanion laws of California.Date
A,l.ant 309 — EXTERIOR LATH
NONCE TOAPPLICAN'1:If.after making this Cerifcme of Exemption,you should 310 — INTERIOR LATH
Nurture nte subject the wndur x Onmisa:lion provonf m
isi ,of Lam).Cock,Yom
u m '
Q fnnhwult complywithsncl,rokion,,,.thi,,o ni Ishan leduunel revoked.
z — 31.1 — SCRATCH COAT
CONSTRUCTION I-CN DING AGENCY 313 — ROOF NAIL
1 hereby afroge
.than them is a construction lending ancy for the pcndonfi ce
of the wmk fur which this,Noun is issued(Sec.3W],Civ.C.)
lcadr,,N:m.e 501 — FINAL ELECTRICAL ENERGY
Lender,Addm,s
U O l ccddy that l have mad this application and nom flat the.bnve information is 502 — FINAL PLUMBING ENERGY
'�. L.. correct.I agree no comply with all city and county ordinances and state laws miming 503 — FINAL MECHANICAL ENERGY
U to building construction.and hereby authorize representativex of this city..)enter upon
p W theannv uncounted NufsnrFillnoecammparp•,,c,. 504 —
FINAL BUILDING ENERGY
E., 0. (Writ ll,mc ill uot.indemnity andk ph' I:. the Cry CuIl¢n' na,mr,t
m Imb _TI 1 1g 1 , see south 'r I y .y g,mst,aid 505 — FINAL ELECTRICAL
U Z Cit) in ounw,miscal Ill ginnin,al Ihiyperant.
AI'PIICA UNDER ANDSANDWIILCOMIIYWITHALLNO POI� 506 — GAS TEST �r ?
souac EGULnT RUS, 4�Z� , Issued by: Dale'
signature Appca.wcnmranm. DoT_ Re-roofs 5@8 — FINAL MECHANICAL
HAZARDOUS MA'I'IBIAI 9 DISCLOSURE
Will thealaphruntor clam lmddingnccu,nnl,mrem handle hazammas.naledal Type of Roof 'S@9 — FINAL GRADE
as defined by the Cupcnio Municipal code,Chapter 9.13,and the health and Safety
stile.5o.,ina 25532(x)] S 1 @ FINAL PL NN I NG
,,vets "^ All roofs shall be .510
�lsge ted oto{�tQ,�}n �.o I + l ue installed.
Will he arpuaut fir rumor build.ngncapanl..,ser wai,menlfit desice,wlmmn Ifaroo(is instailed'ibi outP7rst bsl5t9inifi`f lin �bcCiUt{;Y t fee to remove
emit haaunlous...ennan.i u s m chimed by the Bay Area AirQoal'ny Muna,,emot
Di...iom3 all new materials for inspection. Applicant understands and will comply with
0Yex °No all non-point source regulations.
1 have mad the hv.rdou,matenuls mm
qu.remes under Chapter M1 95 of the
Cliih)rmw Health&SWaly Cade,Seclion,35505.'-55.33 and 25534.1 under%leod'hut
if the hum)ng does no'e'urcntlr rave a moundAu t it k no,m,ponsihir.........lily la,
oa., (or mere i mems w ''h Ibe mal,drrt m heumee of a Cenirac fit
oaup.mr.
Signature of Applicant Dale
n.aumn .est, ent Date All roof coverings to be Class `B"or better
OFFICE