01120020 CI BUILDING DIIVISION PERMIT
O CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
01120020
OWNER'S NAME: APPLICATION SUB DATE
FREDERICKS OF HOLLYWOOD 12/04/2001
4r ONE:
1HONE: SANITARY NO. CONTROL NO.
w ARCHITECT(ENGINEER: BUILDING PERMIT INFO
U BLDG ELECT PLUMB MECH
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LICENSED CONTRACnOR'SDECLARATION Job Description
O z-R I hereby affirm that I ora licensed under pro.isinns of Chapter 9(commencing
xa� with Section 7000)of Division 3of,he Busyes and Frofessiona Codaandmylicense DEMO.OF INTERIOR/ 1937 SQ. FT.
E.1 is in full for Ind effect. �S
_mw� License u.tr 76 aS� PHONE# (310) 827-8525
0 a. y�atC S DECLARATION j 3 u G /" ARCHITEC...DECL RA ION
1 undcnumJ my Plans ehall be usca as punlic rtcnNs
Y I,icenud Professional
fid❑❑
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's Licenu Law for the
following mason.(Section 7031.5.Business and Professions Code Any city or County
Sa ❑
which requires a perall to constnict. It mprove demolish,or repair any stmc um
co _,priono u uanu also req rc m ppl ant for such permn mflcangncd untement - - - .-.-
,hath Ic dp ua no h p sof meCnmmnolsLccnuisw(Chnpter9 1 S t. F our A ga +S a[ion
(cont nngwnhsectwn,7OrA) fD'vsion3ofthc Busncyand Prafessrons Code) tiff_�_�l,('A1trq.fj our
Y3Z��Ia_F se;.S:
u thm he w caempi rhemfrom and the hasis for the alllged esemptiori.Any vtolauon
-of Section 7031.5 by any applicant fora permit subjects the applicant to a civil prnelty
rofnmmnrcthanrvehundrtddmlus(s5W) -3 1 kON 9WffibXM Occupancy Type
°Las owner Orme property.or my employees with wages as their sole compensation. '
-will do Me'work:end'Me'strat um is not intended or offered for sale(Sec.76 ,- - -- ---- -ASS - - - -
Businessand'Profensions Cade:The Contractor's License Law docs not apply to an equtre nspec Ions' '` '•''��i
owner of property Who builds or improves thereon,and who dreg such work himself
or through by own cmpinyece,provided that such improvements is sol art not intended or
-bfferca'for.1.1117,6owcvcq the building�or imProvemimt is sold withi'n'one year of
completion,the nwnerbuilder will have the broken of proving that he did not mild or
improve for purpose of sale.). i
...___... .... _... .._- _..._. ....._.. ...____.. ..__. _..__...___.._._._._...__.._ _.. ..._._ _ .._.--- ___.___.r
°I es owner of the propcnYam caclusivcly rontracting wnM1 licensed cuntractorsm - _ - - - -- -- -- --�-------
command the the Proj<ct(See.lois,Business and Profession ills or The Impulses
Mellon, :.i'u-- . .t + s t:
License Law does not rall,-suc to on"caner of property who Wilds seimproves thereon,
9 ` ' ond,whgc License La such projects with a commnorfs)licensed PuraaanLtp Ne.
Contractors License Sec.
_ °Ion exempt antler 5ec ,B@PCfonhix reason
O'nn e " l Date"
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
❑ I have and will provided
o Cby Se ti of Corium m uLabor for Worker's
Compensmion, as provided for by Section 3100 0l the Labor Calc, rot he
performance aide wurk for which this permit is issued..
❑1 have and will maintain Wo
iker's Compensation Insurance,as requited by Section
r. 3700 of the labor Code,for the performance of the work for which this permit is
Bed:My Worker's Compensation Insurance carrier and Policy number an
r. ._ �(
r. rl' .t�k i s'i 1%: 0o1 c���qq(�� '� qU 'at .:,y�T,>q '• _vy�. t r . .
CERTIFICATION OF E%EMPl1t7N FROM WORKERS i.. :l.Y},�,r tt •.•a g.N L:
(This senionn tlnot be'com lewd if the is for oneh hundred dollars •...._ ...• - '---_ -^-_--- - ..._.....---- - .,_--_.,.
_y...- COMPENSATION 1 SURANCE' ....�. .. ... ..._.-------- ._-......._..____..
I�...• ce p ' permi ' un Bare . ., •., G.sll pall I,:
(S Uld)o(Ieas,) .
,;. le reit Out de,perForrompla,Ofn - k for which dx t ' .- edl -II;, ,
shah temploy a y Pcr I f yneAA q t r th W k rs
ComPen.m onj a� I
.Appl c .,QYYf�
NOTIC PLICANT Ifft I g h n f m (Exempt on you shaul0 t
Z bccom mb3 a Meet k C mpe sat p' .'ons of th Lech Cod mst
you u
Q Q forth th ply with such provisions or this Permit shall be deemed revoked.
E V
. CONSTRUCTION LENDING AGENCY 'sf t" %L
5. f,I hciebyuM.that mere is a construction lending agency far rhe perfrrmance s
W.tr ofthd wark'for whichda pe t d(S 3091 Co.C.) __ ._ t.
QLend Name '..u. ..tssue ,s . . ,,,,t ...... ._. -_ _... .__. .
� Z Lende Addrt
V' I stonily that I have teed this application and state that the abuse information is
;1 Cohen.I agree to comply with all city and county ordinances and state laws relating
. O t.7 m building construction.and hereby unfuriu mpreuntedves of If city to enter upon
r� he above-ralmooned property for inspection purposes.
,. ,f•4 (W'e)igrteinsave.indemnify and keep hamdess the City of C.p;ninb against
V] liabilities,judgments,costs,and expenses which may in any way accme against said
uV V
V z City in conquevice of the granting of this peimin. -
'APPLICANT UNDERST"FISAND WILL COMPLYWITH ALI.NON.POINT, Issued by: r Date
S UMC REG sl.An ' ' . " y'
Llt�eo� $l�i2.8-Da
Stimulate,ofAPPImam�tor '� -. •'••) ;'-Date ' Re-roofs
HAJARDOUS MATERIALS DISCLOSURE
• W ll the palmars car fuldne Wilding occafmar,stom 6,handle blinandour nuallind Type
o'tf R*o/of(,.
ss d f ed by th Cupertino Municipal,Code Chapter9 1E and h Health h d Safe,, : f
si k'
Salina,
erf code n23x.1
°ves' ' t ®" It
l roofs shall be msp+e( (�d: t k _ g r' - _•;,.
poor[o any roof ng material being Installed, _
Will the applicant rt r b lti g occupant use equipment de.aewhich If a roof is installed,without first obtaining an inspection,J•agree to remove
huh Nous rcom at ndfned by dam'Bill A Ail Quality Management ,
.ra <t materials new ma[eals for mspecnon. Applicant understands and well comply with
( Yes all non=point source regulations.
1 have read me hazardous materials mun icinim.under Chapter 695'of the
Califomie Health&Safety Code,Sections 25505:25533 and 35536.1 understand that
ilthcbui"o,"does not covendy nave atewnL that it is mY Cespoisibiloy to notify the -' """ -"- "'_.... ....... ....._ ... _._ .._._ _. _ ___. .
bcCop
or
Olthe requirements which must bemci prior to issuance of o Cenificme of '
°"° Sy t • t Signature of Applicant _ Date
Owner_ ma:;=ea agent ,— �,, Dole All roof coverings to be Class"B" or better
.. ..= OFFICE .. .. . _._ -... .. . ._ ... - - -