02060125 CI BUID NGUDPERTONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
18860 TILSON AVE 02060125
OWNER'S NAME: APPLICATION SUB DATE
JOHN ROWE 06/20/2002
PHONE: SANITARY NO. CONTROL NO,
ARCHITEC MNGINEER: BUILDING PERMIT INFO
u- BLDG ELECT PLUMB MECH
Y (
o,a V6 l-7
Z y o, LICENSED CONTRACTOR'S DECLARATION Job Description
O Z_ 1 hereby affirm that]am licensed under provisions of Chapter 9(commencing
rnFw wimSemmn] ) fDivisionJoftheBuxines aPmre::i°nacWe.anay r«n=< ELECT SERVICE CHANGE 100 AMP.
eea4f is In full force J t. O
z s a License CI cs_ O Lie. a
�a5 O a O Contrue-
F ARCfi1T[CT'S DECLP ION
<j understand my Plane.shall be used as pa ac tecnNc
.ac o O Licensed Professional
OWNER-BUILDER DECLARATION
uai 1 retai rlfirn tom 1 1. eBusin from the Catamount's Co License Law for she
F Z a following remora permit
t ]onstr Business and Processions Code:Any citystructure,
E 2 p which requires a permit re uirew4 eller,improve,demolish,fi repair my sdament $2000
p`d13m -Prio to ,aur alsorequires UeaPPlir tl such fiction un file astertW su¢mcm - -
tnatne fhangilpnnaenn mepmv: n nn c uactor uanselmwtenapterq Sg F44 loo Area,. Valuation
ar g ithset m00) toil 3 fine e ; ss and Pod e„oa,,CWe) i't'P1+ �� 37S1t6'p�45:`00;t•` j.'.��i�,''
or char he Ii exempt therefrom and the basis for rhe aIlijW aemptinn.Any siolaurn
of Section 9031:5 by any applicant rut a permit subjectstoe.11, am toacivil penalty b
ter not mare than five hundred const,($sBB). 103 UF
UFr er .:.a t, Occupancy Type
C I,a.,owner or the propcnn or my employee,ploye,with wages as their one cnpensmion. R
-will thew and the structure <not intended o'o( crc -osae( pl - --- S
304 Reueii
Bas - e 'dY f sio Code;
qhe C mann -License Law does
s not ripply m an 505 - FINAL ections
owner ofh his o y Who build.opov,T improves thereon and who cones such work himself
or
or through his own employees. Wilding
cost inch improvements are not intended or
offered'Tor ale:If,however.the building or improvement is sold within one Year of '- "'"_.._. ......"......._.._.._.. _. . ................__._...._. .__..-_-..__..__..._..._. _.___.__..... ...
completion,the owner-builder will have the burden of proving that he did not build an
improve for p s po'eof sale.l. t�
.._ . ... ._ r .-haps. ... . .. _.. a. .._ .. ... . .. ._..___..._. _ __ _. _. .
OLI ownerohne pmpcey,am allusivelycnmcictingns xR:)Thcontractor,', - of '. 9'f
ns c License
theLaw
project(Sec.]BYI.Business and Professions CWey The improves
n, f I a
'- License Law does not apply w ss owns of property who halide e ar veetntothe JUN 2 6"20 02'
.i
and who comraas.for-such pmjccu with a condactorts)licensed pursuant to roc .... _._.-_ _ __.. _.. ..... .. _. _... .. . .
Conuacu is Licenm Law. .
0l am exempt unJer Sec; - ;B&P C for this rcawn
Owner' BUILDING
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of,the following deelamtions:
❑ 1 hale and Will'maintain a Cenifica¢of Conserv to self-insore for Workers
Compensation, as provided for by Section 3700 of the Labor Code. for the
s. Performance of the work for which this Permit is issued.
01 have and will maintain Worker's Compensation Insurance,as acquired by Section
t
3700 of she Labor Code,for the peiformance of the work for which this permit is
issued.My Wodor's Compensation Insurance carrier and Policy number are:
C CERTIFI ATI'ON OF EXEMPTION F OM WG KERS Z� ..{htV ei. s f Ph1 i
CONPHNSA]'IONINSURANCE•' ._"�' t' __.. . ---,----__. ... .
(This eel'on need rat be co npletW If the Pennit i,for in.hundred cinhar, r '
(S 100)or less)
.. . _
1 ttnify that in the perfomrann or tha work for which this permit is issued.1 - l Fi •t
ot ,jmy P Y
Cnn in r, r b nl n th W k ri -
Compo t Le f C l f D t
Applicant
ppl _ ... _._ .". ._ _...._...
NOTICE TO Vto the or If. Rmakingn sif m IE pt y should '
frac subject the such Im Cnmpen t provisions of the Lobo Cad y must
O O Innh the ply winos hp rase rr th Permit,hal l bed coed revoked
r - - -
" :CONSTRUCTION LENDING AGENCY','
ya ' I hereby affirm that there isconduction lording agency tui the perlormawe"
W floeWork- f h hrh p ni s;.i J(Sec tBq] Civ.C _ _ _ x., ... -,., ._„ ,.•mss --- ._
4.Q Lend Y
U O is
1 l to that co t all
city and
� d state that h information n
s. F obuild I agree to comely with hereby
city and my ordinances arJ.cite laws relating
to building mentioned
namesiona,r,y febyauthtina Io representatives rf thio citymenter upon
};(� the No, is.to property fm if)and
purposes.
Fey. eWelugme to costindemnify nnJ kaphamyi in
.,Or aCupertinoagainn
Vi liabilities,judgments,rams and expena,Which may in any way acerae agnin.a snit
V'z City in donsegncna of the gmndng of this pe . -
AI'PLICAN'r UNDO RSM. SAV,t41.L )SWLY WITH ALL NoNiPOINT
__M .crL; ��20 Issued by: Dale
gnnturcr
head impactor .Dme Re-roofs
IIAZARDOU MAT 1tLS DISCLOSURE
Wild, ppl he t ruture bu'IJinB u p m sto oro dl h No.n,aterm ._._Type of Roof - _- .. .. . . .-.,..,... ..:. ... .,. .. -..._ ....
asdef edby rh C pen M 'p Col Chapter 912,and thHealth and Safety I r
Code S clan 255321a)e 4.'s ) `3
�r All roofs,shall be inspected prior-to.any roo5ng,material.being installed.
n
Will the ppl4 t or future building yu Ba Ba equipment t J a,whichwhichIf a roof is installed without firs[obtaining an inspection, I agree to remove
emtl b ra t adl bmc
t yA a U fryhl gcmcm
District all new materials for inspection. Applicant understands and will comply with
°r - all non-point source regulations. - -
I have read the I ax lou,mann-I. re,ainmrims under Chapter 6.95 of the
California Health&Safety CWe,Sections 25505,25543 and 25534.1 understand that
"'Y rhe building Does rot nurently havcatenanqat itis my recponsibilhy to notify the
occupantof the requirements which must bei prior to issuance of a Certificate of
Zd ��ignature of Applicant Date
r rr hetiaW agent Data roof coverings to be Class "B" or better
. . .. . . 1 OFFICE . . ..