03120023 CITY OF CUPERI'INO C� ,(, ACTaRINEORM" A.TIQ�Va�,
BUILDING DIVISION PT,i.RIVIIT ,n. l,N
BUILDING ADDRESS: PERMIT NO03120023
91 non RI)
ER's NAME: PERMIT ISSUE DATE
LLE
PHONE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:O p LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under previsions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of the Business and Professions;Code,and in,license is
„ infullI and meet. g Lic S�8 p T. I . ADD TRELLIS/PATIO/TRASH
Licen
LF
Data
'S tot ENCLOSURE
Q
AS I L I N Qu/�is/ G
JQ22 IundcralanJ my rear f� /"�
yU '
G Licensed Profcssm
TION
S I hereby ar0rm t oto I from she Carlo 's Liccme Law for the
o O following rcas.n.(Secden]03 ,Business and Prafcsaions Co Any city or county
y Z which toyulma a permit toe soon,eller,improve,demolish,or air any slmnum
Her ha its issuance,alcor arcs the applicant for Such Permit Bl signet atammem
that he is licensed p....at to the provistom of the Contractor's Liccose Law(Chniver 9 Sq.Ft. Floor Area Va�gtgo9932
(commencing with Section 7lMID)of Division 3 of IN Business and Professions Cotle)or
y Nat he is exempt motorman and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN NumberOccupancy Type
net mare than live bandtod della.($500). 35907005 . 00
0 1,as owner of the property,or my employees with wage,as their tele compensation,
will do the work,and do,awctum is notintendcdmo(fated for,.].(Sec.7044,Business Required Inspections
and Profeumns Code:The Conlracsors License Law docs not apply to an owner of q P
propenywhobuilds"improves thereon,and who doessuch work him,elforshrough hi, �a�FINAL
own employees,provided thatsuch improvements are net intended or offered f ntale.IL A®�
however,the building m improvement is sold within one year of completion,me owner- SR*.Ts
builder will have the burden of proving mat he did not Mild or improve for purpose of
sale.). S
l as owner of the pmpeny,am exclusively contracting EP
cting with licensed contractors to t 2 12004
o swct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. -
cove law does not apply to an owner of property who builds or improvea thereon,and
who contracts ler aY' projectswith a caausel"(,)licensed puraWnl to me Contractors ��8�®���
License Law. ,
❑lam ea oder Sec. ,B&P C for this mason
ar Dan. '/f,292V
W MPENSATI DECLARATION
1 hereby affnsn under penally of pery one of the following declarations:
❑I have and will maintain a Cenl0case of Consent to Wil"inaum for Workers Compcm
astion,as provided for by Section 37M of the labor Code,for me performance of the -
workforwhichthispermitisissued.
❑1 haw and will maintain Warkers Compensation Laurance,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued. .
My Worker's Compensation Insurance carrier and Policy number ate:
Cartier: Policy Na.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'-
COMPENSATION
ORKERS'-COMPENSATION INSURANCE
(This section nead nm laceon,imed if the permit i,locant hundred dollen(f I W)
or less.)
I worry that in the performance of the work for which this permit is issued,I shall not
employ any penton in any manner an u to become subject o the Workeri Compensation
Laws of Califomis.Date
Applies.,
NOTICE TO APPLICANT.IL after making,his CemiEmte of Exemption,you should
become subject he me Worker's Cam ponsmion provisions of the Lather Code,you must
.J O
C7 forthwith comply with such provisions or this farm it shall he deemed revoked.
ZCONSTRUCTION LENDING AGENCY
'r~t I hereby alrom that mere is a construction lending agency for the performance of
LY 7 me work fur which this permit is issued(Sec.3097,Civ.C.) -
W� Q Lender's Name
Z Lede
nr's Address -
(J C) 1 ttnify that 1 have read this application and suits mat the above information is
Lia F correct.1 agree to comply with all city and county ordinances and sure laws relating to
V building construction,and hereby eulhoria,reprownt oma of this city 10 enter upon the
W abovcmcntioned property for inspection purpases.
gy (We)agree la save,indemnify and keep harmless the City of Cuperino against '
N liebililies,ju men ,costs and expenses which may in any way same against said City
u Z in conscqu n of a granting of This permit.
" APPLIC U ERSTAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR G
la 151 o Re-roofs
'a., 'Plicae muractor i7f Dat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building uccupantstore or handle hnmdous material
ss defined by the Columbia Municipal Code,Chapter 2, d the and Safety
e.Section 255324) All roofs shall be inspected prior to any roofing material being installed.
❑Yes AN.
Will the applicant of future buildi devices which If a roof is installed without first obtaining an inspection,I agree to remove
emhhexardous air contaminants as def c a manly Management all new materials for inspection. -
DlYtflCl7
❑Yes XNo / L
(have rest ch avardommamrialsoamim els under Chapter 6.95 of the Califon
ria Healm& odc,Secdi..25505,25533an 25534.1undmoundthmifinehuilding
Ones not c t ve a mutant,mat it is my reapm"ibilily or notify the oemupam of the
requitomc I co or.C.rdficatoofactipancy. Signature of Applicant Date
•a All roof coverings to be Class"B" or better
weer au ,rived e6 Date