03010176 (2) CITY OF CUPEWI'INO "-'a%>' 'l.,
BUILDING DIVISION PERMIT • CONTRACTOR INFORMATION:,--
BUILDING ADDRESS' DIJOSEPH' S PLUMBING PERMIT NO.
21716 COLLINGSWORTH ST 03010176
OWNER'S NAME: 205 WYANDOTTE DR APPLICATION SUB DATE
KRISTIE LEE 01/28/2003
]ONE: 408) 365-2058 SANITARY NO. CONTROL NO.
ARCHITECOENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DFrLARATION
��,Fi I Wreby affirm that I am licensed under p widani of Chapur 9(mmmeneing Job Description
� with Ser(urAXE.fDienion 3nf NC Businc Pmfestiov C='inl my he,..is 1
inrdlr ander` g/ Cr REPIPE/WATER HEATER
r�z_ Li...Class Lic.N
wDa Conv
hiq RCIIITBLTS D .A ]ON
Iunderswndmyplans shall Wuscdsspublic records 2003
'OWyu
nLLoyS Licensed Professional ,
g!� j OWNER-BUILDER DECLARATION U
Y 2 i 1 hereby affirm that 1 am exempt from the Contractors License law for the ®��
i 6 p O following mason.(Section 7031.5,Business and Professions Codc:Any city or county B
x$(e which requires a permit In construct,alter.Improve,demolish,or repair any structure
Fiy prior In its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant W me provisions or the Comucmr's License Law(Chapter 9 Sq.Ft. Floor Area $65I40tion
(commencing wish Section 71101)of Division 3 of the Business and Professions Code)or
that he is exempt mcrefr.m 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 Occupancy T
not mom than fin hundred dollars EiNKY). P Y YPe
❑1,as;owner of the property,or my employees with wages as their We compensation,
will do the work,and shsstrature is no,Intended or offered for We(Sar.7044,Business tOt —
and Prefassub"Code:The Contractors License law does not apply W an owner of 10 2 - PIERS equlred Inspections
prolixity who W;Ids m imv n,prothereoand wh idas such work himself or through his
ownemployas.provided that such improvements ere not intended or.ffered Resale.If. 103 — UFER
however,the building or improvement is sold within one year of completion,the owner-
builder will ban the burden of proving that he did not Wild or improve for purpose of 104 - REBAR
sate.). 105 - ANCHOR BOLTS
❑I,as owner of the property,am exclusively convecting with Bernard contra tom to 106 - SEWER & WATER
construct the project(See.7W.Business and Professions Code:)The Commons U.
cense law does at apply m an owner of proper,who Wilds or improv memo..and, 202 — UNDERFLOOR PLUMBING
who contracts for such projects wire a com actors)licensed pursuant o she ConOacmr's 203 - UNDERFLOOR MECHANICAL
License Law.
❑I am exempt under Sec. ,R&P C for this moron 204 - UNDERFLOOR FRAME
Owner Dat 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATIONDECLARATION 301 - ROUGH PLUMBING
I hereby affon under Penalty perjury one of the following declarations: 302 — TUB & OR SHOWER
1 have and will m floodo a Certificate of Consent)wlf.insure for Worker's Cumpen-
aatioo,as provided for by Section 3701 or me IaWr Cor e.for me pufmman.of the 3 03 - ROUGH MECHANICAL
work ter which this permit is issued. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Workers Compensation Insurance,as required by Section 305 - FRAME
3700ofthelahor Gdq fond perfo ante ofthe work for which this prmitls issued.
My Workers Cnm nsai nn lnsN ce er and Pubey number am: 306 — HOLDOWNS
Ca
mm: 1 1C �ca+p,�/ PahcyNn: 307 - INSULATION
CERTIFI ATE OF COMPENSAT150N INSURANCEPT ON FROMO K 308 - SHEETROCK
(This section need not completed if the permit is for one hundred dollars SIM) 309 - EXTERIOR LATH
,i`le'a.) 310 - INTERIOR LATH
I notify that in the performance of the work for which this permit is issued,I anall not
employ any person in any manner in)as to become subject o Oc Workers''Compensation 311 - SCRATCH COAT
Laws of Coliform..Dam
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you shnuW 501 - FINAL ELECTRICAL ENERGY
0zbecome subject o the Worker's Compnamion provisions of the labor Cade,you most 502 - FINAL PLUMBING ENERGY
forthwith comply with such provisions or this permit shall W deemed revoked.
0 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
F Iherehytifumthmsherc;sacaswetionlendingagencylortheperfotmaneof 504 - FINAL BUILDING ENERGY
C, > me work for which this permit is issued IS".3097.Civ.C.) 505 FINAL ELECTRICAL
UU G
Lent's Name - ^
D Z lander'sAddress 506 - GAS TEST
O 1 ccnee that I have read this and coup and surd[hat he shout sus relating is 507 - FINAL PLUMBING
D.U enmecn.I agree to comply wish all city and county ordinances of and sum laws relating e
Q building consWainn,and hereby eumnrimrtpmunutivcsofthis city mcnurupon mc 5 FINAL MECHANICAL
>' Uj aWvc-mentioned property for inspection purposes. O9 FIN
L>r (Wc)agree m save,indemnify and keep harmless she City of Cupnst s against
U to iMI (-PAnP 11
nconseq judgments,e costs and expenses winch may in any way same against said City C, Gi
V APPLICANTeof UNDERSTANDSof this AND WILL COMPLY WITH ALL NON-POINT Issued by51 - WORKS Date
r�cfioa
E LATION ,2 p
a�` / -,p
-d Re-roofs
ApplicanUConuacun Dam
HAZARDOUS ATERIALS DISCLOSURE Type of Roof
the applicant or future building occupant store or handle humidities material
y the Cupemno Municipal Code,Chapter 9.12,and the I]calsh and Safely
Code. n zss3xa)7All roofs shall be inspected prior to any roofingmaterial being installed.
s nthe applicant orffuture building acupam use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
ous air m asom us,as defined by the flay Area Air Quality Management all new materials for inspection.
❑Ycs
1Karnmadshchvs ,a wdalsmquimmenmunder Chapter6.95ofthe Cali(ot.
nia Health&SafdyCnde,SectinnQ5N13,25533 and 25534.[understand mat if fbe Wilding
does not currently hers a tenant,mat it is my responsibility to nol rgcupant of the
requireme M. must N mel PbrInissuanceor.Cenifciflil s cr. Signature of Applicant Date
Ow crimhomedseem Data All roof coverings to be Class "B" or better