05010088 (2) CPCY of cUPER'PINO
BUILDING DIVISIONPI;RMTr 1CONTRACTOR INF.ORMATIQN .
BUILDING ADDRESS: COLOA CONSTRUCTION, INC PERMITNaO5010088
6674 CLIFFORD CT
OWNER'S NAME: PERMIT ISSUE DATE
ANNE LING 1671 CANYON VIEW DR. QIZ14/2005
E: SANITARY NO. CONTROL NO.
(408) 891-2449
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+op LICENSED CONTRACTOR'S DECLARATION O O O O
F❑ 1 hereby arum that I am licensed under provisions of Chapter 9(commencing Job Description
fi5 with Section'/Q10)nroisig..Sof the Business and Professions Code..nd my license is
m mu to.and efmCL REVISION--IN HOUSE USE ONLY
License ClassLic.4
=tee Date Contractor NO NEW PERMIT ISSUED/ORIG. #04010142
L'££tJ` ARCHnRCT'S DECLARATION
C C< I understand my plans shall W used as public records
,,u
Licensed Professional
g OWNER-BUILDER DECLARATION
Ya S 1 hereby affirm Nat I oro exempt from the Contractors License Law for the
00 fallowing mason.(Section 7031.5,Business and Professions Code:Any city or county
<m ff which m,tires a permit ,,construct,alter.improvedemolish,nr d,dr any stumume
prior o its issuance.also requires the applicant forsuch permit to file a signed.rtatemenl
=.xo that hat iafcensedpursuant todue provisions ofthe Contraetoraucenselaw(Chapter 9 Sq. Ft. Floor Area Valuation $0
rt— (com mencing wi ih Section 7000)of Division 3 of the Business and Professions Codc)or
But he is exempt therefrom and the buil for the allcgcd exemption.Any violation of -
Section 7031.5 by any applicant for a Permit ubjects the applicant to a civil penally of APN Number Occupancy Type
not more Bud fin hundred dollars(i500). P Y YP
❑L as owner or the progeny.or my employers with wages as their axle compensation. 36924051 . 00
will do the work,and me shomo m is not intended or offered for sale(Sec.9044.Business
and Professions Code.The Contractors Lic nsa Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himse0ar through his
own employees,provided that such Improvements are not intended or offered for sale.If.
how er,the building or improvement is sold within one year or Completion.line owner-
but lder will hast the burden of proving Nat he did not Wild or int prose for purpose of
sold,as owner othe property,am exclusively contracting with licensed contrtors acto
comwa the Pone
roject(Sec.1044,Business and Professions Corl The Contractor's U.
cerem Law does noaapply to an owner ofpropeny who Wilds or improves thereon,and V
who comracu fm such produce wit a contractors)licensed pursuant o the Contractor' C
Lot
Law. •\C`��\ .
crept der Se<. B&PrCfnInhi��� wsIIIrcazon
Duke v
WORKER'S COMPEN ION DECLAR Duke
I hereby affirm under penalty Of pc0ury One of the following declarations:
40have and will maintain a Ccrommic of ConsenOo self-insure for WorkersCompcn-
sation,az provided for by Section 3900 of the IJbor Code,for Ne fMrtmmance of the
work for which this permit is issued.
0 1 base and will maintain Worker's Compensation Insurance,m required by Section
3900 of the Labor Code.for Ne performance of the work for which this permit is issued.
My Worker's Compensation Insurance Cartier and Policy number arc:
Carrier. Policy NO.:
CERTIFICATE OF EX EM MON FROM WORKERS'
COM PENSATION INSURANCE
(This section need not W completed if the permit is for one hundred dollars(Stoll)
or Icas.)
1 certify Nat in the"Ilonsanec of Be work for which this permit is issued.1 shall not
employ anypcom az
t any manner set to become subject to the Wormo*Compensation
Laws.(California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should
become subject to the Worker's Compemation provisions of the Labor Code.you must
0s) forthwith comply with such provisions or this permit shall W deemed revoked.
Z .~N.. CONSTRUCTION LENDING AGENCY
I hereby affirm that docre is a construction lending agency for the performance of
5 the work for which this permit is issued(Sec.3W7,CO.C.)
17 Q Icnder'a Name -
z Lcnder'a Address
;J Q I Certify Nat 1 have mud this application and sum that the above Oronnuiun is
y F cancel.1 agree to comply with all city and county ordinances and stale laws relating to
DU building construction.and hereby authomr«PMXntatiwa of Nis city to enter upon the
0. aWw-mentioned Properly for do mtmpurposes.
(We)agree to save,indemnify end trop harmless the City of Cu,nino against /I
tin liabi lilies,judgments,costs and expenms which may in any way acave against said City
JZ in co scquenec of Nc grunting of thiapermit. V
'—' AP LICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- DINT Issued by: Date
SO CE RE�kgU�LLATIONS.
;Nn e LC2' / 4/z- TRe-roofs
Sign um of Appecanuconwcror Diob
HAZARDOUS TERIALS DISCLOSURE Type of Roof
Will the applicant tar future building Occupant store or handle havrdous material
az defined by the Cupenino Municipal Code,Chapter 9.13,and the Health and safety
Code.Section 25332(x)?
❑tin 9N. All roofs shall be inspected prior to any roofing material being Installed.
f Will the applicant or future building Occupant use equipment ordeviccs which If a roof is installed without first obtaining an inspection,I agree to remove
d haiardnus air conuminams az derided by the Bay Arca Air Quality Management all new materials for inspection.
District?
Yes
I have read the hzaatdous materials requirements under Chapter 695 of the Califor.
nice lical0&Safety Code,Sections 35505,35533 and 25534.1 undknund that if the Wilding
does not currently haw a denand that it is.my respmuihil By to noddy rho..'sol of me
rcyuirtmcros which PWW mlpdortusmancc ofa Ccniricate ofgk; a412� fgnature of Applicant Date
1111`` J All roof coverings to be Class"B"or better
Owocr authmirtd ogcnt Das
C