04010035 (2) 4
CITY OF CUPEICHNO
BUILDING DIVISION PERMITa,CONTRACTORdIINFORMATION
BUILDING ADDRESS: STEPHEN JOHNSON CONSTRUCTI MMITNO04010035
157 CLEARCREEK CT
NER'S NAME: PERMIT ISSUR DATE
ONE: SANITARY NO. CONTROL NO.
(408) 399-4479,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
oop LICENSED CONTRACTOR'S DECLARATION - G� O O O
Y F 1 hereby affifm that 1 am licensed under pmv nous of Chaplcr 9(commencing - Job Description
SZm with Section 7")of Division 3 of the Business and Professions Code.and my liccrve is
H in full to.and effect.
3 License Class Lica REVISION--ENCLOSE PROCH FOR BARHROOM
:mow Dain COntraemr NO NEW PERMIT ISSUED/ORIG. #03110072
ARCHITECTS DECLARATION
�i u 1 understand ory,plans shall W used as public records
key Licensed Professional
OWNER-BUILDER DECLARATION
a£ 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following reason.(Section 7031.5,Business and Professions Code:Any city(it county
m which requires a Permit to construct,elite,improve demolish.or repair any atrvcture
Zy prior to its issuanre.alm requires tncapplicant for such permit.filcasignedsomment
zo that he isOCensedlmreanitothe provisions ofthe ContractufsLiceneLaw(Chapter 9 Sq. Ft. Floor Area Valuation So
I-$ (commencing with section 701)07 of Division 3 ohne Business and Proressions Coale)or
i — thin he is courim,therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mote man five hundred dollars f$500).
P Y YP
❑ 32618018 . 00 .
will do the work,and the swcture is not intended or offered for sale(Sec.7o44,Business
and Professions Code:The Conrraclori Lienee Law does not apply to an owner of Required Inspections
property who Wilds or improves thereon,and who docs such workhimselfor through his
own employee,provided that such improvements are not intended oroRcred for sale.If,
however,the building or improvement is sold within one Year of completion,the owner.
builder will have the burden of proving that be did not Wild or improve for pury0se of
sale.).
1,as owner of the property,em exclusively contracting with licensed contractors to (/
construct the pmject(Sec.70x4,Business and Professions Code:)The Contractor's Li.
cense Law does not apply t0 an owner of property who Wilds or improm doemon.and.
who comraets for such projects with a conron"'I II no d,tomenuo the Convector's
License Law.
❑lam Zr .B&P Pr J
Ni
(/// \J
/ Date
W K R'SC P ATION DECIARAT
I Mreby affirm untler penalty perjury orc��of the fo owing140
antions:
I have and will maintain a Certificate of Consent l-sal Dimum for Worker'sComPen-
sation,as provided for by Station 3700 of the Letter Code,for the Poolmormtce of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of Ne work for which this permit is issued.
My Winks s Compensation Insurance cauicr and Policy number art:
Cartier. Policy N., _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE i��.s.�yj
(Ibis section need not W completed if the permit is for one hundred dnllve(SIM)
or less)
I twiry mal in me perfomnnce of the work for which this Permit is Want.1 shall nut
employ any person in any manner so as to botrome subject o the Wmkeri Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of Ute Labor Cook,you must
.J.z ed.
forthwith comply with men provisions or this Permit shall W deemed revok
zy CONSTRUCTION LENDING AGENCY
F" I hereby affirm that there is a construction lending agency lot the Performance of
R' the work fur which this permit u issued(See 3097,Civ.C.)
W Lender's Name
�,Z lendcri Address
V O 1 cenify mat 1 have read this application and soon inn the above information is -
LL H Correct.la&Me to comply with all city and county ordinances and sum laws matingto
0building construction,and hereby aithorim representatives or this City to enmr upon the
shove-mentioned property fur inspection purposes.
F G
(We)agree to save,indemnify and keep harmless the City or Cupcnino against
N
liabilities,judgments.costs and expenses which may in anyway accrue against said City C
U z in conseyuc of the gmming of this T< it.
^ APPI- UNDERSTA S AN"WILL WITH ALL NONPOINTIssued by: Date
SOUR G LATIO
Re-roofs
rg feofAppticaN/AC RDOUS MATERIALS DISCLOSURE .iPlocierDam Type of Roof
Will the applicant or future building Occupant store or handle haardous material
u defend by the Cottonton.Municipal Code.Chapter 9.12.and the Health and Safety
^ole.OYesffen zss3z(a)a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant future building Oc:upant tun equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
not hamfdnus air contaminants as defined by the Bay Area Air Quality Management
Disvict? all new materials for inspection.
❑Yea N
Lmvemadthehavardr mm crialsmquimmenLsundcr Chapter fi.95of Ne Califor-
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oa Health&SafetyCWe.Sectmis 25505.1553 and 25534.1 understand Nu if the Wilding
does not cu n I nave a enang th it u y rape s billly m notify do.aupadd of thc z LLL
my.imm nen mast W m t suanae.fleemfiam.r �.payay� 7 ' nature of Applicant Date
e urauthomedagent Dare 1 roof coverings to be Class "B"or otter