00110127 (2) CITY OF CUPERi'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
111.6 ELMSFORD DRIVE CONTROLLED •SYSTEMS 0 CAI_IF. 00i.1a127
OWNER'S NAME: APPLICATION SUB DATE
LIPSON 2283 MORA DR 11/28/2000
• PHONE SANITARY NO. CONTROL.NO.
(415) 964-8:,54
Cloole ARC141TECI'ENGINHER: BUILDING PERMIT INFO
COUE BLDG ELECT PLUMB MEC14
IF-�y I.ICCNSRD CONRACTOR'S DECLARATION Job Description
z O�'S 1 nmchy a0lrnm that 1 um Ileunaed under Providoro'of chu err 9
o z— pi a.'immn¢acing P
pmF�i with fall
I...7lXXB of Dlv6inn3 of the❑usineas and Pmfcsxions GNe,uiW mylicense
us ill°luereem R L' REPLACE FURNACE AND ADD A/C
z a Lwrma loss `7-0 Lie.n 7 f
uKi 3 m y Dale / �.;Y^la_t¢_ Cmnmeu
C'— AltClll'I'IiCI'S DLCf tA'1'I<N /
i1=°g l undunwnml rimy plans xmJl he need as pub a records P(Jyj/'/,yP_yg�-61
x O O LiccnxJ Pndcsxinnnl /
OWNER-BUILDER DECLARATION /
w o 1 I hereby umrm that I into exempt from the Conuacmr's License Law far the /
?a following mason.(Section 703I.5.Business and Profession Cole:Any city or county
N C which requires a permit to consumer,alter,improve,demolish,or repair any structure
as polar ten its issuance.also requires the applicant for such permit In file a signed alatement
Nat he is licensed Pursuant o the pr.,xmns ohne Contractors License Law(Chaplerq Sq' FL Floor Area I�tiopl
(commencing with Section 7B(IBI of Division 3 of the Business and Professions Code) $
or that he is nmmpt mherefrm and the basis for the alleged exemption.Any violation
of Sttmiin 7031.5 by any applicant for a Permit subjects the applicant in a civil Penalty APN Number
or net more than fi.e hundred delta,($500). Occupancy Type
0l.as owner,of the prperty.armyempmyeeswith.rngeare,did,sale ammpensafiom, 23507033. 00
will Jo the work,and the structure is not intended or offered for sale(See.71A4. -
Business and Prorevsiuns Crede:The Contractors License law does not appy to air Re
tqailed Inspections
through A.eout enlglo,ces bond,nrividedte,suchandwhoem, such wodnded if 204 — UNDERFLOQR FRAME
E P e provided that such improvement
is aid
arc not intended or
completion.
sone.I rr-bui erun miming er hnpmofprovm Bald widdd one year or 301 — ROUGH PLUMPING
ip...e for nate owner Mtildcr will hove the huNen of proving rh;n he did oat build or _
mpri�e for potence it nwe.3, 303 — ROUGH MECHANICAL
111,EEa ownar ofiw inrpe ..'Iesem.ivel➢"mmding wit fioetoed cetera,'^m to 304 — ROUGH ELECTRICAL_
ib o"ieo vn5 7(14 oto moCdrI fir t ....... SIDS — FINAL ELECTRICAL
ind I . u't ""'j,ch eth a P ty ho) r p ul r r
mJ 1 t n.-tiu I p'i (.-with ( ( la) I u mseJ pt rsm n metric
Cmnmelers Lice"'e I"w' 507 — FINAL_ PLUMBING
01 uta cscnmpt under Sec. ,B&P C fir this remsnn
Owner Prue 508 — FINAL MECHANICAL
p
WORKER'S COMPENSATION DECLARATION .514 — FINAL PUBLIC WORKS
1 hereby aBirn.under penalty of pe jury one of the following dcc6mtions:
❑ 1 have sad will maintain or Cerificme of Consent mo self-i...re for Worker's
Compensation, as provided for by Swion 37W of the Loner Cede, fill the
Ishou nancc of the work far which this permit is issued.
111 have and will nminmin Worker's Compensation Insurance,on resound by Section
3700 of the lab..Cale,for the pe,from...r,of rhe work for which this permit is
I...ed.My /k�r Com •nsaaliion lnsumus,cart ie andP icy number are:, •
Carver: l ✓) w` P"Jit,No, 2 2'
CL'R'1'IFICA'TION GP EXEMPTIO FROM WORKERS'
COMPENSATION INSURANCE fU '
(oris section need nn(he,,m,le¢d If the permit is for one handled dollars '
($Bon)
I ceriry(hat In tiro ponmnnoec of the work he which tura permit is ismed,I
shill not enipiny Eloy perm..In any reamer xi us or become srole'to the Wirkoee'
Com"u'm o I Laws of Culiku nin.Date
Antillean(
Nuncio TU A1'1'I.ICAN'1:It,utter making this Cend,rec of Eaemino n,you should '
z Obecome xMdre,r ,,tire Worker's Cnmpcnmtin I prvidem if the Labor Curie.you must
forthwith comply with.such polo....or this permit shall be deemed invoked.
F '4 CONSTRUCTION LENDING AGENCY
7i hereby ulOrm that there is acnrewnion lending agency for the perfuronce
of the work for which this pennim Is issued(See.3097,Cie C.) r
Q Lender's Name
7 Lender'.¢Address `
I,enily that 1 have rnul This application and sore that the above iaf smmtian is '
[r ¢term.I agree to comply with all city and county malmam ee and state tax's relating
V
to building conswction.and hereby mdome mpremnuthe,of(his city to cater upon
} �]
the obnvc-mcmionN property ha imilenim Durryrsea.
E. 0. (We)agree to save,indemnify and keep harmless the City or Caperton again
V] liabilities.judgments,costa and expenses which may in any way accrc against said
V Cite in comcyucm a ill(hc granting of this p¢rtnil. xn, ^ ^
AI 'LICANT UN "an n' WILL COMPLY Wa AIL NON I �2 V ^ t�
//Iy�NJ� Issued by: CCCC / Dat
sigma o nr p`Ecanocarmemr Dat Re-roofs
IIA%ARDOUS MATERIALS DISCLOSURE,
Will thoapplk:mmer Bnnre buikii..grccuRmt.vole or handle h:rzonlonsmme^al 'Type.of Roof
'(s delionl by the Cupeni..o Man"Ithol Cafe.Chapter 9.12,and(he Health it Safety
Code,Section 25,p2007
Dyc' 0 N All roofs shall be inspected prior to any rooting material being installed.
Will theapPlic'oml or now lsiilding occupam use equlpmeot ordcvices which ll'a roof is installed without first obtaininan ins ection, I a ree to remove
emit P.I.1 us air ennotninums m defined by the BayAreaAr crabby hfnag
nement g P g
District' all new materials for inspection. Applicant understands and will comply with
0 Yr., IDNo all non-point source regulations.
1 have read the hazardous inommN requirements under Chapter 6.95 of the
Capron.Iieitim&Safety Crede,Sections 25505,'_5533 and 25534,n umde,mnd that
if the building docs not currently have a tenant,that it is my responsibility it,nmify the
occupant of the reyairements which mor he net prior to issuance ofa nIGcom of
eeypancr'
/I r" - Signature of Applicant Date
owneroromna .m gem n„ All roof coverings to be Class "B" or better
OFFICE