01100088 CITY
I BUNGDSONO
BUILDING IVIiiNPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
958 WESTLYNN WAY # 2 KOPELS DAVID N AND BARBARA S E 01100088
OWNER'S NAME: APPLICATION SUB DATE
KOPELS DAVID N AND BARBARA S E 10/12/2001
PHONE: SANITARY NO. CONTROL NO.
G a z ARCHITECUENGINEER: BUILDING PERMIT INFO
H O O BLDG ELECT PLUMB MF,CH
y i LICENSED CONTRACTOR'S DECLARATION
Iberebyaffirm mat lam licensedunderpmvisiansof Chapr9(commencing
Job Description
'ytt°u with Section7")of Division 3 ofthe Business and Profusions Code,and my license REPLACE FURNACE .
[Y Z is in full force and effect.
zoaa Littnse Class Lic.g
O a O Date Contmetor
i 3 u 1- ARCH TECT'S DECLARATION
se ec
I understand my plans shall be used as public rme,
c
3d O O Licensed Profeseimul
'x o ce OWNER-BUILDER DECLARATION _
w-m 1 beery affirm Nat I am exempt from the Convector's License law for the
z i- following ewer.(Section 7031.5.Business and Professions Code:Any city or county $400
See CCp O which q pe it t tru t r,h ni,mve demolish or repmr any stiu n
63m "With to6 Iwteg Iheappl¢artfM s,onrRm,llLGenseLr,(Chaprrcnl -. . _g -F �I�,f,
(commencing
commnet he sclicensed Se pursuant 70Wo b6 s omof NC Contractor's Business
prod Pe law ons Code)9 f ,, .+ i,3.90527Sh .� � s r .,y i�ir'�'sa Valuation
(camerae g with Section]O[ql jDF on 3r t the e'ed ss esti Professions ! ;,'6 `j o 1( ()U 4
.r that M1c pt,hcrtfr efid the bas s for the allegeVl ekemplhn Any violation 1
of Senior 70313 b pep, for a permit sohiects the appl cont m a c vil penalty
ornm mortm eWldred mnars tsSBo). PN -' Occupancy Type
m 30� — �H PLUMBING
arer of the propert,or in,employees with wages as,hear sale compensation.
wi11 do the work,and the stiucmre is not immdcd or offced for sale(Sec.76th,
Business ad Perex,mic,Code:The Cimmomr's License Law does not apply to an 304 - ROUGH E$WgP'ffyMTStions•'
owner of property Who builds or impmvex,brown.and who does such work hitrseH
or through lox own employees,provided nbar such;mproyememx are not intended or. 505 — FINAL ELECTRICAL...... ._
oBeted far We.if,however,the Wilding or improvement is said within one year of
ompletion,the owner-barlaen
ilder will have the dof proving that he did not build m s i
507 — FINAL PLUMBING I '
improve forputpmeafrule.). 508 — FINAL MECHANICAL
D 1,us owner of he propenY am exclusively common,with licensed cmumseb u to a C G® ; s
consuuct the rot(Sec.70ski,Businu earoadode
Professions C :)The Contractor's
License Law docs not apply in an owner of property who builds or improves thereon,
.. and who contracts for.such projects with a comentor(s)licensed pursuant to the
eont turla
a License r
me m� re R&PCf mix so. OCT 2 2 200
Date
O ER'S COMPENSATION DECLARATION BUILDING
1 hereby affirm under Penult of perjury one of the following declaretiom:
p ❑ 1 have and will maintain a Certificate of Consent,o seffinsum for workers
S Compensation, as provided for by Section 3700 of the labor Code, for the
perform race of the wart for which this permit is is acrd.
ave
❑1 hand will mammi W.I Compensation Insurance,u mined by Section
3700 of the labor Cade,far the perfommnce of the work for which this permit is
_ firm MyWo,kers Compensation lnsurrnce curler end Policy number em: _ .. .__.__
.. Cnmr' +• Policy Nn �i •.a 1xLt I .s I,%,i:
CERTIFICATION OF EXEMPTION FROM WORXERS'I
COMPENSATION INSURANCE'„ .-
Mis seelion need am be completed if the permit is for one hundred dollar
(HOE or less.)
'I cenify that in the performance of the work for which this permit is issued,l - v• •, _ _
shNl not employ any,person in tiny manner so as to become subject to the Workers '
Compensation Laws of Califomia.Date
.Applicant ._
NOTICE TO APPLICANT,If.after making this Certificate of Exemption,you should s "
become subjecto the Worker's Compensation provisions of the Labor Cade,you must
M
Q 0
fowith comply with such provisions or this permit shall be deemed tevoked. 1
Ez
CONSTRUCTION LENDINGAGENCY�
" " a -
1 heteby aRmn that there is a construction leading agency for the performance
of the work for which this permit in inured(Sec.3097,Co.C)
Ianderx Name
� z Lender's Address _ a,
C.7 0 1 cenify that I have read this application and state that the above informnion is
W E., c.111.I agree to comply with all city and county ordinances and state laws relating
C fJ ,o Wilding consuumion.and hereby authonu representatives of this city to enter upon
rT W the above-mentioned pmpcny for inspection purposes.
�.a.Oe (We)agree to save;indemnify and keep harmless the City of Cupenmo against
Fy rA liabilities,judgments,Was and expenses which may in any way accme against said / G i V
V-� Cit in5anseyuc (the gr RIS eamit. - e
' SOP CA 2ErN k Rfi. WILL .1PLY WITH NON ,)INT Issued by: Dale
LL.
xx
Ig of AppFc on actor / �, Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicmtl or futtirt building occupant store or hsrdle haradams madmidf Roof
as defined by Nin
Ne Cuper t Municipal Csde cluipw 9.12,end the Health and Salary' Type o {r` .see ♦- i
Cuda Section
OYu 25533(U^.. "Ohio are.. :'1.. I a ! :)',s "`.xri4+ '°•E •( n ' • '
�`" �.,a All.roofs.shall be,inspected prior.to any,roofing material being installed.
'Win the applicant or future building occupant use wt+ipment or devices which. If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminants as derided by the Bay Area Air Quality Management
Dit-' all new materials for inspection. Applicant understands and will comply with
(1 0Yei ON" all non-point source regulations.
yrs+ I sae;and the'h s6okins mamnab rtquiemennsunder Chapter 6.95 of the
Calif. a Heollh&Safety CWe,Sections 25505,25533 and 25534.1 undersand that .
'lithe ilding does not mrtendy have a¢nant,that it is my responsibility to notify the _ •
&c am bf the re a menti which m ei prior to issuance of 5 Certificate of
"p.n`c,.. �' - Signature of Applicant Date
c
'ow, sum xed.c Date All roof coverings to be Class "B" or better
OFFICE ..