04040061 (2) 11
;,EDING
ITY OF CUPERI'INO °'+° ;e "' zJ` "•'
BUILDING DIVISION PERMIT �CON1=RACTQRjINFORMATION "
ADDRESS: PERMIT N004 04 0 061
3.91 BOLLINGER RD
FR'S NAME: PERMITISSUEDATE
ZENAIDA N BAILON 4
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
vOo LICENSED CONTRACTOR'S DECLARATION
CFF 1 hereby atOrm that I am licensed under provisions of Chapter 9(commencing Job Description
SZz with SemiunI Mg)f Division 5 cram Business and Professions Code.and my license is
;„ in full force andcffecl. MOVE WALLS
p q z License Class Lic.g
Dan.Contractor
ARCHITECTS DECLARATION
Q 1 understand my plans shall he used as public retards
D U
;O Licensed Professional
OWNER-BUILDER DECLARATION
<f 1 hereby affirm that I am exempt from the Contractor's License Law let the
O O following mase...(Section 9113 t.5,Business and Pmfcainn Coda:Any city or county
S$ which requires a permit to construct,alter,improve,demolish,or repair any stmcture
iy prior to its issuance,also mquires theapplinmforsuch permiuu Ole asignedsucrearn
< that he is licensedpunumattotheprovisionsoftheConlracturiLicenseLaw(Chapter9 Sq. Ft. Floor Area Valuation
�O (cum mencing with Section 70M)of Division 3 of the B usinces and Professions Crated or
$
that he Or exempt thetefmm and the bais for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 39f�$ll @Iger00 Occupancy Type
not mare Nan five hundred colla..(55001.
❑1,as owner of the property,or my employees with wages as their sole compensation.
will do the work,and thealrucu m is not intended proffered for talc(Sec.304,Business
and Professions Code:The Conuanofi License Law does not Apply to an owner of Required Inspections
own
proopanywho builds or i provided that
Ihmon,and who ts am not
work himself oor ffered
Ma
howemployecsildinorimm vcmcuch nlps mid within
m intended moaered for seta.If, 4 //
however,Ne building or improvement i[cold within oro year of completion,the ower. Ar
huildefwill have the burden ofproving Nat he did notWild pr improvefm purpose of
ale.).
13 1,as owner of the prnpeny,am exclusively con racting with licensed convectors to
cpnsmuct the project(Sec.9064,Buatne s and Professions Cpde:)The Contractor',Lt.
come Law does not apply to an owner of properly who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant o the Convector'. —^
Cleanse law `
❑la a tand,,Sec. ,B&PC far this an
n Dale
W RIE C MPEN rT10N DEC ATIO4
erebyafOrmunder penalty of Perjury an the following declarations:
1 have and will maintain a Cenihcam of Consent to self-insure for Workeri ComPem
.tion,a provided for by Section 3900 of the Labor Cade.(pr the p ormcarana of the
work for which this permit is issued.
❑I ban and will maintain Workcfs Compensation Insurance,as required by Section
3700 of the Labor Code,fpr the performance of Ne work for which this Permit is issued.
My Worker's Compensation Insurance cafrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EX FM PrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bromarered Blue permit is(mane hundred unit.(SIMM
pr less.)
I minify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner an as tp become subject to the Workets Compensation
Lays of Celifomia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the latu fCode,you must
.JO forthwith comply with such provisions or this Permit hall h deemed ranked.
z CONSTRUCTION LENDING AGENCY
t-r 4I hereby alfvm that time is a consuvaint lending agency rot he Performance of
C't F>-r the work for which this Permit Is issued(Sec.3093,Co.C.)
W Q Lender's Name
Mz Lender's Address _
V C) 1 cenify that I have mad this application and state that the above infomuiun is
D, (~ cortan.I agree to comply with all city and county ordinances and state laws relating to
0U building convection.and hereby authoring repommmiws of this city to enter upon Nc
r 4 Ahavemcntinned property for inspection purposes.
(We)agree to ave,indemnify and keep harotlea the City of Cupenino against
rFs f/) liabilities,judgmenu.enter and eapenses which may in any way acerae again..said City
U in consegance of the granting of this permit.
'-' APPLICANT UNDERSTANDS AND ILk COMPLY WITH ALL NON-POINT Issued by: Date
SOU EREGULATIONS.
Re-roofs
c of ApplicanVCo uactor a¢
✓ HAZARDOUS MATERIALS DISCLOSURE. Type of Roof
Will the applicant or future building occupant norc or handle heardous material
defined by the Cupenino Municipal,Code,Chapter 9.13,and the Hcalth and Safety
,de.section 35553(a)9 All roofs shall be inspected prior to any roofing material being installed.
Yu
Will the applicant o fulurc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.it haeard ore air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
uict?
Yes
I have read the havardo smaterialsmquiremcnts under Chapter6.95 ofthe Califon
nia Hcalth i Safety Code,Secuuns 35505,35533 and 35534.1 umk..mnd that if th building
dura nes Oy hate a tenant,Nat it is my pgnsihility to 4ik Pent of the
d. me hichmast mctpmmi ccAf Ccrufcay. Signature of Applicant Date
m
All roof coverings to be Class "B" or better