02100031 (2) CITY OF CUPER'1'INO --
BUILDING DIVISION PERMIT CONTRACTOR INF�ORMATIOW
Bull-11C TTO SHILLCREST RD PERMIT N102100031
Ow9k1R vNETZEL APPLICATIT"MSY2OO2
]ONE: SANITARY NO. // vv // CONTROL NO.
ARCHITECT/I!NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo+00 LICENSED CONTRACTORS MOR'SDECLARATION
cuF 1herebyaffirmtbut IamIimeBuunderidProemofChapmr9(commencing TEMP POWER Job Description
<3 with Smsi,)n]ggp of Division3nf the Business enJ Pmfessinna CnJe, nJ my license is
infull furcande n. Lr
o z", Data Class Conn.�L 5.',
OZ-0 Dam /n%1/ice Controcurt — P/L-f—
F=� ARCHITECTS DECLARATION
C� 1 undcrsmnJ my plans shall k uxJ es public rccnNs
, U
m3 a� Licensed Professional
H t�0, OWNER-BUILDER DECLARATION
se <7 1 hereby affirm that I ora exempt from the Contractor's License Law for the $150
d60o following rcuno.(Scnion]I131.S.Business and Pndessinns CltJc:Any city nr anunly
an$E which requires a permit m construct,alter,improve,demolish.or repair any suuawre
prior to its issuance.also requires the applicam fusion permit m Glc a signed statement
thalhe islicensed pursuant to she provisions of the Contractor's Liecax Law(Cope,9 Valuation
(commencing with Section 700))of Division 3 of the Business and Professions Gxle)or
_ that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of PMN Occupancy Type
ammmethurfive hundred aolmrs(s500). 304 - ROUGH ELECTRICAL
P y YP
C'2.as owner of the property,or my employees with wag.as their elle cnmns
peatinn,
will do the work,and Ne structure is not intended or offered tarsale(See.7044,Businam
and Professions Code:The Conwcmr's License law Jens not apply to an owner of Required Inspections
property who builds or emphases thereon,and who daenouch work kmxlf or Nhaugh his /
own employs,provided that such imphavemw t arc nm ear ofc m o0ered for cele.If.
however.Ne building or improvement is hath within ala year of mprove for
the pose of
builder will have the burden of proving that he did not Wild or improve(nr putpnx of
.Jr.). /
❑1.as owner of the Sec.70propany..Business exclusively ao fessi ns with:)The contrecmrs t.
came La the project(Sec.o a 4.wneofand property
who Wilds
Cale:)The Cs those',) ad
cense law dceh not appy to an owner of pmpeny who builds or improves Contra,and
who contracts for such pmjecu with a contmcmr(s)licensed pursuant to Ne Contractor's
License Law.
❑ 1 stn exempt under Sec./p sty .B&P C/for Nis rcaum
Owner ;Y41 /w�Data /,J3 O
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to ttlGinsute for Workci s Campem
nation,as provided for by Section 3700 of the labor Code,lou the performance of the
work for which This permit is issued.
have and will maintain Worker's Compensdion Insurance,as required by Section
90(t of the Labor Code,for the performance of the work for which this permit is issued,
My Worker's Compensation Imsumnce eerier and Policy nuntkr am:
Cartier: 5;4.�'e Far,I Policy No.: _
CERTIFICATE OF EXEMPRON FROM WOR K ERN
COMPENSATION INSURANCE
(This section need not k complcwd Ifflue permit is I'nronc hundred dollars(six))
M)axe)
I certify that in the perlbm mance of the work for which this permh is istted,I shall not
employ any person in any manners,)as to kcome subject n lire Workers''Compaimmoon
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,arta making this Ccndi.te of Exemption,you should
Become subject to the Worker's Compensation pmvi.sions of the Labor CnJe,you must
O O forthwith comply with such provisions or this permit shall k deemed revoked.
z ^'
CONSTRUCTION LENDING AGENCY
_y
[-� l tomabywhich ret Ne Nero iseed(Secs3007,lending agency GR tire perl,)rmanceof
mai the work for which this permit is issued(Sec.3007,Civ.CJ
W� t7 Lender's N.M.
.7. z Le der Address
U 0 1 cenify that 1 have read this application and smut that she or.inRnmatiuo is
[k. F consul.I agree to comply with all city and county ordinances and stale lows ceasing In
0 building construction,and hereby authnnrc representatives of this city I,,cuter upon the
W above-mentioned property for inspection purposes.
C (We)agree us save,indemnify and keep harmless the City of Cupeni no against
Co) liabilities,judgments,costs and expenses which may in any way accrue against said Ci ly
U Z In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON POINT Issued by: Date O 3 ^D
SOURCE REGULATIONS.
Re-roofs
Signature mf ApplicaO Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will are applicant or future building occupant.Chscore or handle hazardous material
as re,Sac by she 32(a)l nn Municipal Cssde,Chapter 9.12.and tk Health and Safety
Code,Senium 25532(,))?
❑Yes �[Nn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant he future building..pant me equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7d.a
mit M000dous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
istrict?
❑Yes on
1 have read the hamahms materials requimments under Chapter 6.95 of the Califon
iafl"llhASafetyCa .Secde.25S)5,25533.d25534.I aWersmnd Nosifthe wilding
not amoam ¢ m,N y n' ilityto notify Ik neupam mf the
yuirem mnmam n or ,) acemrcamoramp r' Signature ofApplicant Date
_ J 5
Owner or ausho' dagent I ale All roof coverings to be Class "B" or better