03040049 CITY OF CUPEwrINO .. '' »e b '» ''_-"N s r k,,V PK
BUILDING DIVISION PERMIT SCONTRACT , 'iINFORMATION x
BYI�I�Ir�Dlf�ss:TANTAU AVE SYL-MAR CONSTRUCTION PERMITNO.03040049
D � OFFICE PROPERTIES TRUSr 1310 TULLY RD. # 114 . prR'MIT"W723/2003
(408) 293-7969 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0 0 0
1,z LICENSED CONTRACTORS p DECLARATION Job Description
I hereby effvm that 1 em licensed under provisions of Chapter 9(commencing � p
Mwhom Se lion 11fMD of Division 3orlhc Rusin cu dProfcssiuru Cad .oil my license is
< mmnm. eery 7 TENANT IMPROVEMENT I��N�L� LE93
y License Lia a
3y, Dare�Cunl�aG�aar// -
e R II'ILCTS DEGLT,mea
L IundcrstanJ my plansahell he used as public r,c,rds
311 MAY 2 2 2003
yA
Licensed Professional
vt OWNER-BUILDER DECLARATION
F I hereby arbrm that 1 am exempt from the Convenor's License Law for he BUILDING
�1 V 1'1L®IIVPI^
00 following reason.(Seetiun 71131.5,Business and Professions ID
Code:Any city or county DA
3$R! which nquims a permit to construct.eller,improve,demolish,or repair any structure
-Zy poor k)its lssuanec.also mgklfcs the applicant forsuch permitta file a signed statement
arQ
hat he is licensed pursuant to the Provisions Of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area $15��I�on
fit- (commencing with Stetson 7")of Division 3 of the Business and Pmressions Cook)or
9 Net he u exempt twmfmm 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 ,k pp����fg,�ri},,��,,��{{..��
oat more Nan five hundred doll..(55W). 3 I9118Tn! '3l 00 Occupancy Type
❑T.sa motor of theproperty,or my employees with wages as their sole compensation,
will do she work.and theawnum,is not intended w offend far sale(Sec.7094,Business 101 - FOUND '' Inspections
and Professions License Law The Contractors LiceLaw does amt apply to an owner of
prpeny who builds or improves thereon,and whodM3 such work himselfor through his 102 - PIERS
own employees,provided that such impmsements art not intended oroffered farads.It. lO3 — UFER
however, year building or improvement is sold within one ysof completion,the Owner.
builder will have the burden of proving that he did not build or improve for purpose of 104 - REBAR
oath.).
I,as owner of rise property,am exclusively convecting with licensed contractors to 105 - ANCHOR BOLTS
construct ti.project(Sec.70".Business and Professions;Core:)The Contractors Lt. 106 — SEWER & WATER
mese Law docs not apply to an owner of propeny who wilds or improves Neuron,and, 2O2 — UNDERFLOOR PLUMBING
who concocts for such pmjects with a contncmr(s)licensed pursuant to the Contractor's
0m Law.
❑1 am exempt under Sec. ,BAPC for this mo
son 203 - UNDERFLOOR MECHANICAL
Date 204 - UNDERFLOOR FRAME
Owner WORKER'SCOMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury ate or the fallowing declarations: 301 — ROUGH PLUMBING
have and wil l maintain a Cenificate of Consent to eel6insum for Worker'sCompere- 302 - TUB & OR SHOWER
.all..,u Provided for by Section 37W of the L<wr Code,for the perfmmance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
O 1 bare and will maintain Worker's Compensation Insuramx,as required by Section 304 - ROUGH ELECTRICAL
37W of the Labor Colic,for performmtt of d.work for which Nis permit is issued. 3O5 — FRAME
My Workers C. ern 1 nom ea ierand Policy numbers.: q 306 — HOEDOWNS
Ce 'er �], Policy��
CERTIFICATE OF E%EMPr10NF M RKER ' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or Ice.)rThis¢miim.cad Out wcompleted HIM Permit 4 for one hundred doRars(5IM) 309 - EXTERIOR LATH
1 ecnify that in the performance,of the work for which this Permit is issued,I,hall not 3 10 — INTERIOR LATH
employ any person in any manner an u in become subject to the worker!'Compensation 311 SCRATCH COAT
Laws of California.Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT.If.after making Nis Contracue of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation previsions of the Leber Cole,you must
�O fonhwitheomply with such provisions mots remo ilswll w deemed revoked. 502 — FINAL PLUMBING ENERGY
Z� CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affirm Nat Nen is a construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY
Y O7 the work for which this permit is issued(Sec.3097,Civ.C.)
req Lender's Name
Y Lenderame 505 - FINAL ELECTRICAL
s N
jp I sentry that I have read this application and stat,that the chow infnrmatiun is 506 — GAS TEST
y P comer.I agree to comply with all city and county ordinances and state laws relating 10 507 - FINAL PLUMBING
�U building construction,and hereby aatholu.pres,ntatins alibis city to enter upon the FIN L MECH ICAL
above-mentioned property for inspection purposes.
)~ WL (We)agree toson.indemnify and keep harmlessthic City OfCupenino!glioma
0 — FI
r h liabilities,judgments,coats and expenses which may in any way accrue against said City
;J ,'Z, in croulomnee of the granting of this Permit. 5 — NG
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by: 4 _ C WORKSDa[e -
SO CE EGUL TIONS. a
Re-roofs
PIS,
eof ApplieanvContractor a
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant mor,or handle hayamous material
u defined by the Cupeninn Municipal,Code,Chapter 9.13,and the Health and Safety
ew Sectiona2ssu(an All roofs shall be inspected prior to an roofing material bei.
❑Yeas P P Y g g installed.
Will the applicant or future wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
a0Nnus air contaminants as dcfned by the Bay Area Air Quality Management
District? all new materials for inspection.
171 Yea Nn . .
1 have mad the usurious materials requirements under Chapter 6.95 of the Califon
nix Health&Safety Cock,Salons 25505,35533 and 25534.1 undersvW that if the wilding
[dois not cmnnlly ban a rew am,that it is my resp,mihility m nou Iy Nc Occupant of J¢
'),n} 'men(�mjal,(w�met�ptigarl�kt/is_suanceooraCe ,.tears aney. Signature of Applicant Date
authoh'y �'�',�I� All roof coverings to be Class"B"or better
Owner ser auhorimd egcm —��at