02050014 TY
CI BUI DING DIVISION O PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22763 VOSS AV JACK CORSIGLIA 02050014
OWNER'S NAME: APPLICA IONS B DATE
.JACK CORSIGLIA 05702)2002
• PHONE: SANITARY NO, CONTROL NO,
C x i ARCHITECDENGINEER: BUILDING PERMIT INFO
O O BLDG ELECT PLUMB MECH
<n LJ IU 1---t L_..I
LICENSED COM1TRACTOR'S DECLARATION
1 heart term that 1 am licensed under f Cha ter 9(commencin Job Description
jN-a prOviaiOnsO p g ADD ELEC CIRCUITS/AIF COND. '
t; is in fall foreland of Divisionlofthe Business end Pmfcsxions Cad<.and myli<ense
in full tutee and effeci.
i z K U License Class Co a
O 0 U Dam ad as
ter
a O� ARCHITECT'S DECLARATION
1 underhand my plans shall be used as public records
3 r
ial,
p O Licensed Professional '
OWNER-BUILDER DECLARATION
al o V
1 hereby affirm that 1 exempt from the RATION License Low for the
t?a following manor.(Section 7031.5.Business and Professions Code:Any city orcounty y5`16000
5 o which requires a Permit to construct.alar,improve demolish,or mpeir any structure
a3� prior to in issuance.also requires the applicant forsuch Permit asignul statement Valuation _
Nat W is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 t t
(commencing with Section Wffl)of Division 3 of the Business and Prpfeasinn.s Cure) i' � i':.'3 K� V. f]'�..`tVtFP;h1 ! '4.g'i(
or that he is exempt therefrom and the basis for Ne alleged exemption.Any violation • ' '
- of Section 7031.5 by any applicant for a permit subjects me applicant ton civil penalty
ot
of not me than five handrail dollars(11590). 101�PN1 1i'UT 11T9IDAT I ON Occupancy Type
01,asownerofthe property.or my employeeswith wages as theirsole compensation, 102 PIERS _
will do the work,and the structure is not intended or o0ered for sale(sec.7044, 103 - UFER Required Inspections
Business and Professions Code:The Contractor s License Law does not apply to an
orr of propern,y Wen builds or improves thereoand who ones such work himself 104 - REBAR
through his own employees.provided Nat such improvements ere not intended or
offered for sale.If,however:me budding ter improwomm is rum witmn one year Of 105 - ANCHOR BOLTS
completion,the owner-builder will have the burden of proving that he did not build or
improve far'um aw of sale). 106 - SEWER & WATER
❑I.:sowncrofthe pmfxs�;.alai exclusiveycontmclingwitnlicensed contractors to 202 - UNDERFLOOR PLUMBING
cOnxwn he pruce,(Sec.71)44.Bovine::and Professlom CWc:)The C°nharmrs 203 - UNDERFLOOR MECHANICAL
License Law does not apply to an owner of properly who builds or improves thereon,
.radwho.rommch for-such projects with a commatods)licensed Pmsuent tO.the _ - 204 - UNDERFLOORS FRAME .. ._
Contractor's License Law.
0 am axrm aeersre em PC rarmLs reason205 - UNDERFLOOR INSULATION
+L 301 - ROUGH PLUMBING
WOR(ER'S COMP TION DECLARATION 302 - TUB & OR SHOWER
. ,e herebyaffirrnunderpsnal of Perjury omeofthe following declarations: 303 - ROUGH MECHANICAL
❑ I have and will maintain a Certificate or Consent to sell insure far workers 304 - ROUGH ELECTRICAL
Compensation. as provided lot by Se for 3700 of the Labor Code, for the
performance of the work for which this Permit isissred. 305 - FRAME
❑I have aad will mutation Workers CmunKmatmn Ins.mnas,as required by Section 306 - HOLDOWNS
37M of the Labor Code,for the performance of the work for which this permit is 307 - INSULATION
issued.My Worker's Comfar it 1 umnc<ca e all number ere:
;Fat .PaicyNo:'cr TIFICS 308- `- SHEETROCK
LATH WORKERS'; .. EXTERI.OROIONOFEXEMPT + 3 .
INSURANCE N
COMPENSATIO
_ _ _ . .._ .._ .3 1.0'r--:I'NTERIOR-LATH - - _-
(This section aced not be completed if the permit is for one hundred dollars 311' - SCRATCH COAT ( `
111100)or lesa.7
313" - ROOF NAIL
1 certify shot in then in any roa m the wort Tor which this ct to t c issuedWorkc I
Con not employ anti person in any manner an as to become subject to ter waakeR 501 - FINAL ELECTR I CALF'ENERGY
Campcnsation Laws or California.Da"
Applicam 502 - FINAL PLUMBING ENERGY
NOTICE TO APPLICANT.If.after making this Cmificem of Exemption.you should 503 - FINAL MECHANICAL ENERGY
Z become subject o the Worker's Compensation provisions of the Labor Code,you most
p O 504 - FINAL BUILDING ENERGY
north,ithcomply with such pmvisionsorthis permit shauxdeemedrevokad. _
Z
CONSTRUCTION LENDING AGFNCY 505 - FINAL ELECTRICAL 1'
a'71 hereby affimt that there is a construction lending agency for me performance '
Sf the work for which this permit is i...ad(Sec.3097,Civ.C.) 506 - GAS TEST
asp L,ndcrsNam '507 = FINAL PLUMBING
V 0508
Landers Addoes
I arnica mat 1 owe«aa this appfiration aha amu mat me anove inraamation is 5 0 8 -
FINAL MECHANICAL
a E corer.I agree to comply wish all city and county ordinances and state laws relating 509 - FINAL GRADE
O U to building construcron.nndhereby wm°merepre.%crativesothis city toenter
upon
Tor im
he 510 - FINAL PLANNING
tabovemrmionW property prruon urposes.
p
L.
L (We)agree msaw,indemnifyand keep harmless the CuyofCupertin`against 514 - FINAL PUB IC WORKS
SG liabilities,judgments,cost and expenses which may in any way.terve against said
U Z City in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND ' LCOMPId W'ITP ALL NON-POINT ISSUed b Date
SOURCE RF LATI NS a S`•Z— y
Ignmu A,I canucnntmrmc Data Re-roofs .
HAZARDOUS Mn 1 DISCLOSURE
Will Or riptide.,or future buil` c,am Mo.or handle boards.,material Type of Roof - .. .
as der Sea by the Caper'.Municipal Coe Ch pt 9,12.ane the Nealm end sa(gy _ ..
cork.Section 2s532(a) � , .. i s ^ ( ' + .. ' } ', :- , . .. •
- 1)Y. - XN° t '' - All roofs shall be inspected prior to..any roofing material being installed. _
Will the applicant orfuture building occupant use equipment ordevices which If a roof is installed without first obtaining an inspection, I iagree to remove
mit huarduus air contaminants m defined by me Bay Arca Air Quality Management
Dix ian all new materials for inspection. Applicant understands and will comply with
C3 YS, 1<No all non-point source regulations.
I have read the haazadous materials requirements underChapter 6.95 of the
LLL�Liapwrt
lifornia Health Sa Safety Code;Sections 25505,25533 and 25534.1 understand that
me bar
dote not amently havea¢nam.met it is my responsibility to notify the of the requirements which must ber,Inet prior.to issuance of a Cenifiate of
tips° r Signature of Applicant Date
r amnOaiaed agate - Date . All roof coverings to be Class"B"or better
__ _. . .. OFFICE