02050091 (2) CONTRACTOR INFORMATION:
'.CITY OF CUPE6tFI
BUILDING DIVISION„, .., ,-„,PERMITr:..
.•. lyDit4�`JpR (7DY..,AVE .': ... .” ` "� ,...:. COND3TI'ONED'..'AIR-- ----. .. ..._. PERMIT NO.. ..02050091 . .._._
4 .
x�T`ANS�SOIII
LI r HAMID 1,., 1.64'-B -GI-LMAN-AVE,.. $?�"� 2�N. 2 .__. .._ :.:.
7, :PHONE "" "' a": - :, SANITARY N0. CONTROL NO.
„'!,!, (408) 374-6311
X00 ARCHITECT/ENGINEER:' - BUILDING PERMIT INFO
,e F BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
S'a? 1 hereby e18rm that I am licensed under DBSCrip[IOn
jZ= 5 provisions ofChaptcr9(comrmndng FURNACE CHANGEOU'1'
with Section o(pivisionJof the Basi ess end Pmfessiona Code.and my license
jyyJ t n Ilf ode t _7(p Sr' - -
0u L I'G,�_' �ft e `Ci. a
t ! i ,Com c a
I ARCHITECTS 5 D RATIO - .
I d
had 6,plan,,[all he used ublic hemmed R•
i d o Licensed Prof' f ..hot ON NER BUILDCft DECLARATION
I, 1..:, -..,.
a�m ION
1 by ffrin that I am exempt from the Contractor s License Law for the y�677 5
(=Z6 following
ason (Sennon70315 Businessand Professions Code:Anymtyor county I I lu
XM G wh ch qu rc e permit t t alter mpmo c.demolish o reps ny structure - !
n3� 'pre t t c uenc.al req theapplicant for such permit to flea greed matemem ii 1 I 1: I.
mm netelcensed pursua tt-rap tions of m<Conwnor'.Ltt 'law lChapter9 3'7�g1]Q.GHIr�rA@a ti ,_. Valuation
(earnmeneing tura Sc ion,7000)of Division 3 of the BusinessedP fssnons Code) .- '�:" rf V. !- 1,. IIt . •
or that he m efiempi are in and me basis for the alleged exemptori.Any violation
- - - - - - ---
of Se<timi j 31:5 by Ey applicant for a parotin subjecb the epplicam so a civil penalty
nfnotmort maer tianatea d°tajn(ssgo): " _ 204APN NbHMRFLOOR-F ME:� ,., .:,occupancy Type -
131:as owner of the progeny;or my employees with wages as their sole compensation,' ..3.0L--' ROUGH' PLUMBIN
p Y p eended re Use f f IS 7044 _ - ,
'Bollnas,dol acd Profess onswmrk�and eCode ctThe ire tCv sdcricit t conLucenSc to doeshot apply to ..... __.... _...- CtlODsit
w e of r n Whoh Id u rid who does h khimself 30,4 . ROUGH' ELE TRICAL ._ -.:....., ...._
r r el yh h's ply p' 'red ibm 2hp t -i mended o - '
..__. ...... t,_.f .,`. ._ ........_...
pR of xl'Ir,n - m baminge p m that he did hot buil or "' 5 -'-FINAL EliECTRICAli';;
'enmplenon the owner harder will have the harden ofproving that he did nal buil)or
._ impruyefdiparpnxe°ramp): 507 - FINAL PLUMBING
- 508"-----FINAL' MEC14ANICAL .__
[]1 u ounerMthe progeny,am exdusmdy commcung w m licensed mnvectnn io _ •J.
construct the project(Sec.7044.Business and Professions cmc:)The Cuntranor'a 514 — FINAL PUBLIC WORKS - :t
License law docs not apply to an owner of progeny who Wilds or improves thereon,
and who,contras.I.,such projects with e.aontmnor(s).licensed.......t to the
Contractor's License Law.
_ °lam Hemp,under Sec. ',BAPCfor this reason - -� - .1 iOC }
% Ow "': i Date
1. ..
WORKERS COMPENSATION DECLARATION �'N,A,IIrc_1F0
• 1 h by ffrm de pe hy,of p ) ry ne f the toll g d I�mtinns: - Y V! ,
q
° I
have non, Itima t e ' n S t r'3 t e f t If' s error Work the
pompe c sat p dad hi by $ni n 37IXL of m lab i C de, far the 'Jul"'4
performance of Me work for which this peoch sosuul.. � �� '��
°Ili cora Il ma tai W rker's Compen t Y-'u}enc 'as requited by Section BUILDING -'
.
3700 M rah Labor C/mesfim the.peHorm c f the work for wh ebhh tjh s P1ermitt to � I X77
IssTd QK�'11 �k-.mF4l�n las Iiemer end Po�y
.y rl1 -CERTIFlCATIONO EMPf1ON FR OM WORKERS >, }t+5s SKI { ♦: '+ .3 ' - ..Ls I. _
COMPL ATION INSURANCE - -. _ - -_
4..
„ •'•- t t odneed rn be mmpleied if the permit is for one hundred Aull
1
(Thi stet 4 i
-
': i 1 nify th t in the performance f the work for r hi h t, jxrm t "".a
ss r 1
hull t pion Los"
Pe n rinca Dmunner s t becom b)a to theWorkers -- _ .._, _ .. .. ! _ ,_,. _, ------
Compensation
. .. .._.. ..._..... .. _....
It ,
.7 Cppinco etion Lews of Cal fomie.Dale "'
A CEI APPLICANT;If,after king the en fcate (Exempt y '-__.. __... . ..... .... ...... ... . .. _ _ . . .... _ . - -
should ...}��.. ._- .-... _.
NOTIC&TO APP ,
Otechnic subjen t the W k s Co pe sin p Woos of the Lobo Cm you roti;;
fonh nh comply with ch provisions or thisperms shall he deemed racked.
-f
'CONST RUCTION LENDING AGENCY -
�,j- t IfaY ffrm don mere swmlending a
on ge cY f the ped e
rinvnc1 ,
fir Mme eklmwhich mi,+Permit s issued(Sea 3W7 Civ C) "
5'Q Lenders Name-
5,
eme'5. Led x Addrts
•V-'� tl mfythrulha ere Jihsappl ceion andsm¢that the oboe fo minionis _
'fzi..F. fi,agree to comply ih ell city oil county mil ogees and state Inws relating
V' mtichronect ingernt ction,andherebyuuthctiiitmprcscnmtNesofthiscity'..terupon
r..W the. e m tinned p pony ror on impem p ramex. 11
( a) greet s indemnify,and kap hairr s-the City UCuperi'd'against -- -
Vi liab lnics ludgm ts'c cash, :d expenses whi,h troy in any way accrue against said
L) City in Consequence of me gr fag of this perms
PPEIGNTUNDERSTANDSAND WILL COMPLY WITH ALC NON' IN ` 1 :t.' 'P•
URC Rro Issued'by: Date
Signor „(Applies Contrec., me ,s•
j ,HAZARDOUS MATERIALS DISCLOSU ` Re-roofs,'/ ,t,
"rt WdltA'hpPlicant orfuture biking eccupanenone or hardle1 heezfdois maiedal Type of Roof
ai def
ad
t6 C irons Municipal Cme Ch pr r91] hand the Health endSafety -
Cad Section 255321a1 ,y M
Vlfx ❑v ' - dStt° All roofs shalltbe mspe,cted.prior to,any roofing material being installed.
f li. Wll
the,.ppitanto fwpe b 'Iding coup qua equpm for devices which if a roof is Installed'without first Obtainln -in ins ectlOn"I'a ree'to'remove -
m t ha]m dou ntam mit defined by theBay Area Air Qumdy Management 1 .., g P g
leaf ci7 - all new materials for inspection. Applicant understands and will comply with
° P
a all non point source regulations. '
L' I h e rcae:0e hazard us mmerial requirements under Chapin 6.9516f the
Caldomia Health&'Safety Crap Sgnnons 25505.25533 and 25534 1 undcmand mat
if the Wilding does not currently hamort that is my mspo iblty to notify the _. . •. -. ._ .. _ - . _.., .. .. . ...- _._
c pr t /me rrq rem i 'h ch mus;M m t poor to its C ¢t� - '
Occ", y: p�
� �tIA �6 - Signature of Applicant Date _
Uv or Emnnzm gent ��. .Date All roof coverings to be Class "B" or better
t. . . .
� r' ' OFFICE