00050143 (2) CITY OF CUPEWfINO '^
BUILDING DIVISION PERMIT CONTRACTINi2+INFOPl7X IF 'M - . 4:i
fiUlll OQQADIIItESA: PERMIT NO, Q\
OWNEI' AM1iF.: AI'I'LfCXU"N SUFI DRIP. _—')
PHONE. SANITARY NrI. CON'I'I201.NO.
p C Z ARCIII ❑C/IiNCd Nlilili: BUILDING PERMIT INFO
pl O O HI.EO ELECT PLUMB MECH
tt��U LJ L-1
zO C S LICENSED CONTRAC FORS DI CL\RAI ION ,lob Description
II by aI d' ,al Iel"il JI a em' ,
F4tC with S T 70010Jef D':.', 911111ce
ad
- IP- I >' C)lly�myll'oanc
N a Is. r hC el
U Dole GmtroW r
vtcluT17 ' IIECLn n
OI undenwled my plans drill he L. as prbllc reeoN, ��� QrC�
r
pC Iecenr.od Professional
OWNER-BUILDER DECLARATION
W I hemhy'd fled llwt l an,uncap.fmtn thc Cnllllaeler.s 1 iccaso Lawrnr the
y�¢ followingurce" rseccnn70315.Husincss and Prnrcdeier,Calc Any,it,e,ane my
5 x o whel,myriols a pem,il to construct.alms.Unfree,dcmelidh,or tal nir nny tnmuue
pr four'. 'I -. b ppl II ip.- tt fl g I.nlcacru
tn"he is hatteled Trallandn t1 I 'u [ C ''I I' (Chapin-d S Ft. FI p(y Area Ll"LtlOn
(c corner
S e ]'ll I' l tine 3 f h ft s o I I ie m Cndat ���]7/ c
nthenle 031 51)11 t dumb II nllegW p .Any Vint' an
of nousai,dare by any Trolled
east rs Opera,tl,nhjcxls Ise nPPllemt m u civil Penahy
or 01,.a,nrc than 11,oo drd dn1aet ts50d). �� APN Nu bur a �
❑Ina woal rk,and
the s rt to aid of a widrd or os fe ed]or rola( ce.7 nn. �
III[do(liek dd 'I ': t ' t -offered ;I, IS c7oa.]
B and Pat -. c I Th c 1 1 . r 1 chs,h workapply tori, Required Inspections
orTorp npcovWlnlo Ida nr'aprovc,iduration,nl nd,is assnwnrkhilcal of
earough iia Been cay,loycoIl prvvidin Illat unci IDI icat is sol am tit(mended nr
Mures for rule.II,howcvon the l ase nr urdenor llel is sol within one year til'
,mplelinn,the,.w alboiler will have the burden n(pnrvin,ILw he did Bol build nr
impmvc for pnq,osa of sided.
❑I,as owneroI Ha pmpeag an,exclusively clnmtning with licensed cawtvmora to
Immut the pmjcea(Sec.7(W4,Bolin...and Pmra
uaion,Codo:)Th,Cnnmtor'I
out
Lew all Bol apply to an owner of property win brilds or iloptn,a IherLr.
and who contracts for such praires will,a nnnrocna(n)liccnned In...anal m the
Onmminor's I:mrnw Law
❑I;inn exefapl under Sec. ,B k P C fm this ji,tioll
Owner Ere �{p�
WORKER'S CC1M1 ENSAI ION DI CLARA9ION ��r
I herrhy ffmt 1 Penally at pofiny are of the lioll,ill,d f tlo
❑ I ie I II 1 C 'fie 13Closer" m II bar l A '
pe l c provided r by 5 1 B7f111 ,f II t'1 Code, f We
Pel � f1he workl IiI hislounit sissited.
❑Ilarva dIII[faa 1 ' R k ,Cn tad Iuaran '- I 'redbyStallion
3700 of the Labor Cade,rnr the perfol eraca of Ire work for which this permit is
icwuLMy ask",Compensalin I Insofaace cnrricrand Pam bcrarc:
/p Qul� '7
Carricl': O•^ Pnhey Nn.: '56 Q/ 0 f
CERTIFICATION 017 EXEMPTION FROM WORKERS'
COMPP.NSA'I'ION INSURANCE
(This action need Lal hecmnptried Elba par lel is IF ill buudreA dell;eta
IS 100)01'Icse)
I artily that in Iho pedernlanee Ill the work rnr which this porion is issued.I
'hall not employ any persaa In Lilly Insurer.',as¢,become aulter,to the Workers'
Cnalpondulion Laws or California.Date
Applicant
NOTICE TO APPLICAN'C Ir,amt and,ing this Cenlficam of Exompdnn,yna should
z hcenma raker, ,,the Wok,,',CL mperaalion Prues f Ilio labor Club,you Inst
Q rotlbwim cmnply with...[I pmsI..on.or Iris par Iii 0,ufl oha&,iu d mvukd.
L
VJ COa Thera ICfION LENUINGAGI?NCY
Wp�p Ihemhy arena this,herel is esued(See Intl ngagencyfrthr putfumuma
Gti Lea in,work dor which this permit is[snort f5cu 3097,civ.CJ
Q Lender's Name
F5z Lenders AdJtcp
U O 1 fy dial I hacl,truthII ppll I I still t t lie,E ah
with et Y Isar laws Tng
O V fa h l gagree t die ply ihereby
y
by' I I
p - tl : y a p ,
etY/� I
>y W Ne 1 - rd p' t l ec 1 /
�y Oa (µe)'glo I,f III keep honnlwsthe Cly of Cuperl ugi nut 1
Fr 0 Il abililics,j ad,mcnl and cams which rally in any way accrue against said
U i City in cnnsn, �8 ling of this pennh
APPLICA nNESAN WILL COMPLY WITH ALL NON-POINT
RE
.T Ns. Issued by: Date
/sign rnppecaln/Contraclt Eric Re-roofs
HAZARDOUS MAI URIALS DISCLOSURE
can me applicant Ld Plied"bulletin,ocrua t too,orbanme ba.amLns nlJmrlld Type of Roof
as defined by the Culo nlno Munlelpul Code.Chapter 9,12,and fill,Hwllh Ila I Safety
Code,Section 25532(a)P
❑Ye, 0 N All roofs shall be inspected prior to any roofing material being installed.
Will not applicmnill lalmehuddingall all I'llnslariloddeviecawhlch If a roof is installed without first obtaining an inspection, I agree to remove
e a Ilvardaua air mntanfmmas as defined by the Ray Arc.AirQuahly Mnnugemmat
Distndt' all new materials for inspection. Applicant understands and will comply with
Cl Y" ono all non-point source regulations.
I have mrd the hamnlou'laments rgelrcments under Chillier 6.95 of Iia
Caldernm Health&Safely Code Ina25505,25539 and 95534.I 1 ki,rmI]that
inhc bnudin,does art ala' n ten:fah tom B is my mxpnnsihi by lL notify the
cupam ,I the regnlr eh nmst he fall prior m issuance of a Cel dricate of
OcrndnnoY.
Signature of Applicant Date
nanarL l,oriaed'get Date All roof coverings to be Class "B" or better
OFFICE