00080172 (2) CITY OF CUPER'f1NO
BUILDING OtvtstON, PERMIT CPNTRACTOR INFORMATION: -
BUILDING ADDRESS: PERMIT NO.
- I k
OWNER'S NAME: - _ - - APPLICATION SUB DATEKLEIN LES[=IE AND '
J.�
IPHOPI _ SANITARY NO. CONTROL NO,
00 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT I PLUMB MECH
Z S m 3 LICENSED CWNTRACI OR'S DECLARATION Job Dti
O Z glC 1 hereby affirm mm 1 anproisi
.licensed coder provisions of Chapter 9(commesc(t on
p r
enein,
with Station 7t]IHq of Division inti lhctlnsinessdnd Pndecsinns Cone,and my license
in Fall from and I.
���a< our..,ecws, r{e` Contractor
57= TEAR OFF EXISTING SHANE/ INSTALL 40 YR
3 vFOi Dme Q—Z�� NDECCler ¢y�Fp' • _
G ARCHITECT'S DEC IM
m°J 1 under,mnd my,ohm,hall be d,,d a,puhlic records
r
Ile p O Licensed Professional - - - -
UWNER-EIrnal fee,,
DECLARATION
tk++ I hcrehY affirm mal 11. ex®nnl from We Can
ssio n% o Lmense Law.for the '
- Y C following dies.(Section 7f1315,Business and woo do lifCnde:Any city or county
ad O which it,dandies.peon..l ro ones h L ahea improve,den.olis t fi repair vny svuemed
' 3 m poi. I l I. y 'team ppfe t l h pe a is L d,wmmmn s
that he':Ic ,wtp tt theprovisions till Commutator I' : In nd,Co e) S Ft. FIDoorArea
(c thathe'ngwm Sov.mndarad he be J ftile naaedo dP 1 nsCodo) 9' Valuation'
lir that he 1 31.5 by
any apps and the basis formin cs the
exemption.a civ l penalty a '
of Seetinn"!011.5iv anyappllmmtforapemtL-subjects.he upplievm mucivil penalty '
lir not more mon live toonnrea anuar,Psalm, - APN Number '_ Occupancy ype
°1 owner riffle p-p t" Y carldo"a,With ri,,11heirselee penatio..
ill do tire k d the structim,is m l intended or ofercal 1 (Sec.7044, I. :oProfessions Code Contractor's License applyequired-Inspections
(owner of property Who t Ids or inproves thereon,and Who stda work bin,ell `
or through his own employees.provided that such improvement,ore cat intended or offered for sale.If,however,the building p t .x sold within one year of 305 — FRAME
crndtl sit b ld III a burden fp proving Id ,bill r
improvef p p : r 1 ) 307 — INSULATION
°l r l the property,am exc1 : Ir contracting Writ licensed nl t r. 601 — ROOF TEAR OFF
ntaI as 70B aProfession,Care)Tire e t
Iec Law does tapply to 11 ery h builds th
602 — ROOF PLYWOOD NASI_
cIsuch projects with oprammLq licensed par,.ant m me nI ,arad,La . 503
-
who
ROOF"BATTENS
°Iam
in eupt ander Sea. ,B&P C fill this reason F.04 ''— ROOF IN—PROGRESS ' �(�
Owner Data
WORKER'S COMPENSATION DECLARATION - -
I hereby affirm under penalty of perjury one of the following dedamdons:' - -
..° 1 have ma .ill maintain is Certificate of Convent to self-insure for Worker's
Compensation, :tx provided for by Section 3700 of the Labor Cole, for l.e -
performan c of the work for which this comit is issued.
°I have and will nmlntaln Workia s Campanian.lour ance,a,squired by Sdcdon '
3700 of the Labor Code,for the porformance of the work for which this permit is
issued,Mly.Worker's Compensation lnv.mncc carrier and Policy number am:
carrier:V I L&A__Policy No WC lf(up 7Z(q 3 ^ -
CERTIFICA9ION OF EXEMPTION PROTWORKERS'
COMPENSATION INSURANCE.
(Thi,cwaidn need as,be completed if the peon:.is bit line hundred dollars
(S 100)of lex.,) '
1 cmil,that in the perfomaance of the work for which this pom.it its issued,1
shall not employ any person in any manner so as 1ll become subject n.the Worker,' - t.
C r,onad lion Laws of California.Dam -
Applicnda -
NOOCETO APPLICANT:IL afier nankin,this Certificate of E.c plion,you should
Z become subject to the Worked.,Compensation provisions of the Inder Cade,you must - -
0 fonnwilh comply with such provisions lir Ibis pemth shall be deemed revoked. _
r
^F, CONSTRUCTION LENDINGlen AGENCY _ s -
ai w hereby affirm that them t is mastication(Sion lending agency for the performance
W of a e work lisp which this permit u iastma(Sec.309'1,Civ.C.)
Q Lender's,Name
� Z, I,cnder's Address _ •
V 0 Imodify tnat l have rwd this vpplicnlion and stem the,ltie,have information is '
�+ N correct.I agree m comply ,in all city and county mthander,and s,am laws relining
.0 t) to building cararm91on,dnd hereby cmhorize representatives of this city to enter upon
rW the above-manlolled properly for iregarded purposes'
j Qy (W)agree It)sa' d oily and keep harmless theC'ty nfCl riand against - r
r V1 licblls judgments.c :ts and expenses which may in any way accrue against..id
City in cnco .fit,, turningifihispomaL
SOURCE REGULATIONS.UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued '
- Y Date —2 �•{_L
Signature of Applcam/commemr Date Re-roofs
HA7.ARDOUS MATERIALS DISCLOSURE _
Will the applimnt or funded building tpcupanl stmt or htmdle inmraous mmenal Type of Roof
as replied by the Capenim Municipal Cade,Chapter 9,12,and the health and Sefic y, o _ -
Core,Scctinn 25532(x)7 • ,.
0
Ve4 - 0N All roofs shall be inspected prior'to any roofing material being installed.
Will tneapplicant ormade buuam,emnpeotu,aeydflmemtor device,Which If a roof is installed without first obtainingins ection, I a to remove
emit haenNoms it rmi,ld ambos defined by the Buy Area Air,Quality Management an 17 gree -
Di,triet' Iall new materials for inspection. Applicant understands and will comply with
81 ❑reH CI No . all non-point source regulations.
I have rend the charmers materials reyuidmm6t,made,Chapter 5.95 of the
Cal ifomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that ��^��_n...rrr
i f the building tloes not current If have m mmandmas it is a ty responsibility m '''�not ify the ��/(
x pent of mai indents which must No mel print to issuance of a Conti of
Omdpm -
. Signaiure of Applicant Date
Owner or mtherized agent i at,
-,All roof coverings to be Class "B"or better'
OFFICE