02060137 CITY OF G UOPERTNNO
UIPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
7527 TIPTOE LA LENTZ CONSTRUCTION INC J 02060137
OWNER'S NAME: APPLICATION SUB DATE
BILL YAMADA 5087 MAITLAND DR 06/21/2002
PHONE: SANITARY NO. CONTROL NO.
(408) 264-0555
❑ O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
m— BLDG ELECT PLUMB MECH
a i 1_7 u "t LJ
Gc.ay
Z O
LICENSED DECLARATION
Oo, CONTRACTOR'S Job Description
— I hereby vffirmee Ialicensed otChap¢r 9lcommencing
RuiF with Section7")of Division 3of the Business and Professions Code.and mylicense KITCHEN SKYLIGHT/6 LIGHTS .
.n rnn Tome an «em.
O U License Claw ;e Lic,x tiSlofil b
Date Contractor Q3� n _
I 3 u t ARCHITECT'S DECLARATION tL �
Sa a,� I understand my plans shall W used as public records
m W p O Licensed Professional
as OWNER-BUILDER DECLARATION
t� v, 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
r z following mason IScclion 7031.5.Business and Professions Code:Any city or county
5=8 which requires o pemtil m colmuua,alter,improve,demolish,or repair any structure, $3600
ac tz 3 c, -mor to its issuance,also requires the applicant for such permit o file a signed statementcompi
thane'i- i.'I' it pSr i,.nl7q0)0bbc)pofDivi,isofothoefthe Vinea LaicnednPsemLafnarta Cmr9
S.qF . FIQosr,OO;tt•t3ikl (()se1 )
Valuation
mthinMs 5ifnthnli the basisfor theTuddAnyviolation592' 01
-of Section 7033 b tiy applicant for a permit subjects the applicant to n civil penalty
,ofmoreth.n rive hundred aollars
(ssao), 103 APN
03APN�R�er Occupancy Type
❑1,as owner of the progeny or my employees with o'ages as their sole compensation,
will do the work,and the'amrture trout intended oro ere or sae(Sec.7044; 3114 R1
Bas nos and Professions Code:The Comrcmr's License Law dna not apply m on 505 — FINAL EL etionst"
t r of progeny Who builds or tmprova thsuch iand who docs such oink himself
ownc
or through his own howevicea,provided that such improvements are not intended or _
"�oRemlfor dale.If,hdwaef the building or'impmvem'eni issold within one"year of .....__. _ ...._..._....,_...-....._.__ .._..—......
completion,the owner-Wilder will have the burden of proving that he did not Wild or
improve far purpose of sale.).
inims
n La L d
,er flp cP inlayc1M1B b ithI'J sep coev 1M1 1❑1 1m f N p pcnY m I
.. I_
on ont he prii Sec 7044 Business and Profe. CWa:)The Contractor's N
and h c cis for such apro ¢with tractors)licensed pursuant to the
Cono sLicenseW
0 rept under Sec.
_..s...,
B&PCfar his re ,o 0 7 !0
Ownc, ,. . . Data
WORKERS COMPENSATION DECLARATION
' I hereby affirm under penalty of perjury Enc Of the following declamfirms:
❑ 1 have and will mxmmin a Cenificate of Consent to self-insure for Workei s
Compensation, as provided for by Section 37W of the Labor Code, for the
petiormance of the-work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance.as required by Section
37M of the Labor Core.for the pedormance of the work for which this permit is
bonind.My Workers Compensation Insurance carrier and Policy number art:
Cat"ter\ 51iii "Policy Nati/%0/.337_0 j, '.: Fv N"i•"•{i.'•"' + -••.yr ..
,.'JS}II ICERTIFICATIdN OF ETiMPEON FROM WORKERS
COMPENSATION INSURANCE t.,
a I '
` sS ecaian'nceJ nn1 he n+mplemd if the Pennil is for one hunJred dollars '� s' k i' 1-
I,(SIM)or or Iess) .,
t '1 cenify that in the Performance of the work for which this Permit is i.weJ;I
shelf employ any person in any manner en as m become 1.jeif m the Workers"
Compensation Laws of California.Date.
.Aipikn1
Ntl110E'TO APPLICANTi IL altar makingtha CcNRcale nl Exemption,you'should t
become subbm to'the Wdrker's Compcnmtian provizions c,the Lays,Cale,you must
Q O f nhwith comply with such provisions or this p .. - _ ___._ . _ —_ - ... ._ .. . ._._. __ ._.._. _ _ . .. _ _. _. _ ... .
'.rap �4 ":."" 'I 'CONSTRUCTION LENDING AGENCY. I "
1.
N
"'I hereAy affirm that thane iso construction lending agency for the performance
r�-Ir of the work(or which this pcmtit is issued(See.3097.Civ.
Lmdc Nitric -"-'
7 Le Ler,Addresn"
U 0I cenify that 1 have read misapplication and state that the above information is
correct. 1 agree In mmply.,vah ail city and county ondio:mtts and stem lawn relating
:U to Wilding contowon;and hereby authorize reprecenmtivcs of this city to enter upon
the moi mannioned property(or m,peclion purposes.
(We)ugm,m
reese.Indemnify and keep harmless the City„of Cuperium against
U]' liabilities,judgments,costs and expenses which may in any way accrue against.said
U.Z City in consequence of the'renting of this pennil r+
_. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.N'ON-POINT° Issued by: ! Date
S(IURCERF djCA 4NS �/'�� I'
Signature Of ApplicundConlmnor " ' Data t Re-roofs
HAXRDOUS MATERIALS.DISCLOSURL
Will Ihe,iIi c t It b'Id'nb sec p lane or handle hamirs mat
dnuerial ..Type..Of ROOI. _.. ..._. .__ ._ ........ ._-. .. ._ .
ii d t ttcd by the Copan n Mu 'pal Cade Chapter O 12.a d the Health am Safety t
Cal Sect o 255320 ❑Nn'. 1 t t Y t ._A s t ,T ' i'i)1., 1 'j;
Ra % t.l
❑Yep All roofs shall be,.inspected prior,t,any..roofing material being.installed_ „.. . -
_
Will in applicantorfuture Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an'inspecti i,9 agree to remove
main hazardous air conmmmana as Jclm J by the Bay A \n Quality Management
1 Di t t all new materials for inspection. Applicant understands and will comply with
Ova, ON. all iton-point source regulations. '
_ I have read the hazardous m.1cr 1. nqu rtmcmv under Chap er 695 of the'
r
Cal'domia Health&Safety Code.Sections 25505,25533 and 25534.I mnderstan l mon
if the building does matt comically have a tenant.that it is my responsibility to notify the
occupant of the requir mems which mast W mel Prior to issuance of a Cenificae of
' Occupancy. e'
Signature of Applicant _ Date _
7i:1:_ t9
g
All roof coverings to be Class "B" or, better't
Gwmer nr amnnrized ngem
OFFICE -