01020097 CITY OF CUPER•PINO ..
BUILDING DIVISION PERMIT• CONTRACTOR INFORMATION: I ^
1
BUILDINGAUDRESS: I'I11tMIT NO. As .,
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` OWNIH'S NAMH.. ' AITLICAIIONSUBDAI'l
1 16 ZMAN ALLEN AND AGAR M 122 ION ST 01/PCA
PHONE: a - SANITARY NO. CONTROL NO.
L]0Z, AHCIIITECI'/IiNGINEEH: BUILDING 1GRMI'1'INFO
kC IfLI%: Ii1.rCT PLUMB • '-MECH
!z5�� Inureny um inwilvmn<M RACOWS DECLARons XI i+or;er.gaentnennn : , + -- Job Description. -
O� walls f 7(XXgofD' J mom post ,� Ir ( CA had It, Ice
i billf Jctpp
���` 1"mhc ' a 9�_ SOLAR TANK REPLACE '(IN' KIND) r '
,e u Iml C tractor 1�I11
W��ort A �4ITECT'S DECLARATION (J( ` t
k g 1 ale,tand. y jflah5hall be
.u.sed ,p hl or,
S Licensed Pr Jesnnal
OWNERBDDI AHO
I hereby tf that 1 mac PI f m be Connector's
L I for- he
g r'
' -
(S t 7011 5 p i ll l e y an aunty, +. -
te F❑ prior
I y - h t I n p II' f 1 , y t mere - - -
�,3. Prior I s 1 mt pr isio If hpe a is g J:t9•mem
Warn licensediwith
not the provisions lite c I I e 1 I (Chapterq Sq. Ft -ea Valuation ..
len ilk tn4•et 71it sor fb 3fB B . ,rProfession,Clic) 1
• - ooh PIa I IA I� for d alleged ,t i,AtYlat+n
nr le'I IDJI5ny Y PPI' tfr "' e'object,the al Plwnl In acv l perchr
nrhot mntathan Tsehundred refers(S511U) ,; _ APN Number '. Occupancy pe •-
1 us rookie lin e i m to e
❑ wt. p p y,,r,rre r re•wmtwagesaaneh'ulertd6pen,ndnn.
will thecwnro ssi s odsunitIll is not cto',Lie uflLaw for snot iippl it) 4.an _ .
[business and eny Who b cane:qja rosci Contractor',License Law ane.h%ark h m an - n- required Inspections
owner or Pmpcnr won Hund'or itmProae.S mcrenn,arta won n„<"acs work nim,Nr - '
orl1 rough his own employees.Provided that such improvements a not intended ar r
ENERGY
' sainbnor are ytarn 'S0 - 'FINAL PLUMBING E Y
offered fnr xulc.IL inxever,the huilAm tem in xulJ wimin Ino f .k t.' -
r. nmmdnn,,a nwaer-n+tuaer will have nth human or Pm ing mol nn aid not bndd"r 506 •— 'GAS' TEST
improve fnr Purpnso of sulci._ - v - - '• � n
507 — FINAL PLUMBING-
. ❑1,asr of the property,am caclmively contracting with licensed commctors In• '
Lmmmet degnijeet(Sec.7044:Ifusincxs and Profession,Cods:)The Contractor' `
icense Law docs nm apply to nn nwncr of jrropuny who builds or Intp or,thereon, ,
and who ca howl'for such potwith a a+m enot licensed porn nm in the - -"
Contractors License Low.• -
❑1 am eschnpt under Sec .If&P C let this reason
Owner Date - '
WORKER'S COMPTNSAT1ON DECLARATION -
"i oerchy aftimt under Penalty of perjury Inc of me following deckohlinns: -
❑ 1 hnve and will nwintmn'a Cenifcme nr Cnnscm to self-instirc fir Worker's
Comprnenion, as proviJW for by Section 37010 of the Labor Coale, for the
nerfammucc of the work for which o'permit i,""mulL -
❑1 h,,,; I will maintain Workers Crnnperoal nourrico,n.reyoJreJ by Seetlun e
370o ofrho Labor.Code,for Ibe se,formism,of the work fnr which this perout is e I F
5u1a.My Workers Contpensahnn msurana currier and Policy number are:
Cnriee XIIMPOO
"• _ CIiICrIPICAI'ompaNsi%BMP'1'NS RANO WORKERS' s'
- COn1PENSATIONINSUHANCIi
(This satire,hard not he completed irthe permit i'for one hundred dollars 1- -
S 10111 nr lcsv.l
1 chuaybia in th1f fon kf which Pe , issued,sud1
'
'hull t o nPl Y l W eta f
Comb .ref I t[ tc
APPI
NOI ICI IG M P 1 l au nmking d ,Cc vficmc nl x mgt nn,You should -
Oneeome suhjen mine W..Lars Co n,th, min m vi mo ol'the Labor Cale, .it most
for th comply with such Provision'or this permit shall be deemed tevoked.
r ^•,i , ..
•� GONS ,aI()NLENDI NO AGENCY
lB; I Hereby amne titreche is ahtimed(Scen lending agency fdr me Ixrfnrmmec
Leahcwmk lotName ',len Otic Perms is issued(Sec.JIN7(Civ.C.)
y O Leader's Nome
D z Lender's Address
.V
lecruny that] lichi....union isw
Lr..[.. correct 1 agree to c arli with all city and catch y on1munce:and state I ows training - -
C (J ¢,building cnnslmninn.and bench,authorize representative,ofthi,city tocmer upon
•. r�
the above-owntioned prolahly f pr t' P e e ..
E'a Q,r
(We)a" t J .iy aridsee,l ..I d l ily it C p t y'ut • -
..t fn liabilities,jud,neent,cou, ad a,,sio.a,which it,m;in,way tweno,ayanm. iJ
City in amnom,ance of Itegmmingof this pram.- I
/�J^ •/� '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINf ISSUedb .� \ / Date
SOURCE REGULATIONS Y'
sisnaere mnppheanvc.+mmuror - time, Re-roofs
HAZARDOUS MATERIAI S DISCLOSURE _ s
will tot I'lifillon Ili floor bUildfir,occlisho unne ra handle hoemdon,mmen Type of Roof
1,d1boal lrydeCopv( s "tial C it,Chtpl 1),1 2,rdd Width i dSafny -
Mole,Sector 25512(d' .' p
°Ye.. _ - All roofs shall'be inspected prior to any roofing material being installed - -
wBlmcapplicmm(;rntetnaddingneeumtmusecillopmemnrdeviceswhich If a roof is installed without first obtaining'an inspection, I agree to remove
ndtlloo,air'oho not t15 dufiyvJ by 11 Bay Area Air QIiry Munugcncu _
Di,tdm t/ / all new materials for inspection. Applicant understands and wilhcomply with'.
13 Yet,
all non point source regulations.
I Live read the lOtardthis thalCrials railtiffelothilts hatter Chapter fi)5 of the
Cnlil' n'u lY lth&SIpCd S 15511525581 it15514.I' thadIhn
r(thebuildir,clot mran nocaterant.tl t t y p b'11y, n tifyd -
occupant of to oh,un net rh must he it pritir m mucona of a Cen tical f
Oecuparc -
t :
2 O� Signature ofApphcant, Date
oxnernr l»�r�d—gm,,, Wase All rorof,coverings to be Class "B” or Better
" OFFICE '