02120092 (2) CITY OF CUPER'P1N0 ^� "" _ �u �y -���- �*�i
umi.niNc nrvision P�RMIT �GONTRACTOR INFORMATION:
.�. �,,N,
nm�oiNaa>naus: WATERx HEATERS ONLY � PERMiT^'o.
20614 MAPLETREE PL 02120092
OWNER'SNAMG: 97O E . MAIN ST, SUITE ZOO APPLICATIONSUBOATE
HEINLEN ANN 12 23/2002
�oNr:: 415 5 6 6-2 2 0 9 SANITARY NO CONTROL NO.
ARCHITfiCT/fNGINEF.R: BUIL�ING PERMR INFO
i BLDG ELECT PWMB MfCH
0 0 � 0
�pp I.ICF.NSF.DCOMRACTOR'SDIiCLARATION JobDescri �100
�F I h rchy oflirm thai l em liccn, dcr prnvieinns nf Chep�cr a(commcncing (>
wiihc{�u'a��nTxNpnlDivision3nf essendPrnlcssionsGwlc.onJmyliaenmis
��iy�`���a�rr��i.z/ �L, (� 2 WATER HEATER
' ZOY� LiiMs�^l�Ius�1.iC.N /�J �� 7 ���n A L ��
I F=rp Da Nmnca B�d�IL
q ARCllllli I.ANRI'ION
a 1 unAcr.�unJ my pluns shnll hc uscd us puhlic recnrJ.� MAY 2 8 2003
�OWp
u�3 u� LicenuJ Pmfcssinnal
�"�=0 OWNER-pU1LDERDECLARATION
�v�i i f 1 MrcM1y upiem Nai I am cacmpi Gnm Nc Cnmmmnfs Liccnu I.aw for iAc B���p��G
w_p O fullowing maenn.(SCNnn plUl.S,Ousincss an0 Pro(csxinns CMc:Any ciiy nr cnunry
a K�� whicA myuircR u pnmii io eoneimn,eltcr,imprnvc,Jcmnlish.n�rtpair nny xtmcmrt
w—� n��no��a�.a��uo��,maorw���asn�oorNi�omro�s���nr��mw�n��.�e�mnm���i
��< ihaihcisliccnudpursuanuothcpruvisiansnhhcCnnvamnr'eLiccrecluw(Chapicr') Sy. Ft. FloorArea ��I�1�100
��F� (cnmmcncingwithSminn]IXMryofDivisionlofihe0usincssan�YrolcssinneCnJc)or
d�$ Ne�Ae is cxcmp�i�ertfrom nnd N<buu for�he ellegeJ cacmpGon.Any viola�ion ol
' Secuon]07LSbYanYaPVlicamfnnpertni�su�jecuNeepPlicennoacivilpenaltyof
noi mom ihen fvc hundrtd Uolbm(SSW). �' Occupancy Type
�1,as owncr nf Ihc properly.or my employces wilh wa6es ss their snlc cnmpenselinn,
will do Ihe wnrk,md Ne swcwrc is nni imenAeJ nr nlffircJ for sale(SccJ1144.�usiness
anJ Pmfe�iom COJe:'ITe Conuemoh License Lew drce na�apply m en owner of 5 0 6 - GAS TFS' W�0 fIS�CC�100$
pmpeny who�uilOs or improrsnherton,end wpo daf mch woek himulf or Nroug�his
ownemp�oycu.n���a�Naisucnimpro�emenuvenniin¢nncaoeorterea�oeu�e.�G SO'�I — FINAL PLUMBING
hmvevcr,Ne Auilding or improvcmrni i�a�ld wiNin nne yev of compleuan.Ne omner�
huilJcr will have i�e burMn o(prnving Na�hc tlitl nm build m improvc fnr pmpoee of
xalcJ.
❑1,as owner nf Ne propeny,em cxclusivcly comnming wiN littnud cnnvacmn m
conswn Ihe pmjcn(Sea 1044,Ousineu and Profcaeions Co�e:)The Conuenm'a Li� ,
mnu Iaw da�nm eOPly�o en mvner of OmKhY W ho Wilds or impmvn Nerton,enE,
who contrecu for such projecu wiN a conuacmr(s)IicenxJ pursuem io Ne Convacmts
Licenu Lew.
❑Iumeacmp�unJerSea ,B&PCfonhisrtasun �
Owna Dek
W ORKER'S COMPfNSATION DP.CLARATION
1 hcm�y dfirm undce pcntlry ol pe�ury onc nf i�e following Occlueiiona: .
I hevic en�wili maimain a Cmificn¢of Cunum m wlGinsurt for WuAer'eCompcn-
saiion,as proviJeJ fnr by Scainn 3]O(1 nf i�e Lehnr CnJc,fur Nc pcAnrmance o(thc �
work for w�ich Nis pcemii is issucJ, .
❑ I havc anJ will meimain Workcr's Compensatinn Insuancc,u rtyuircd hy Scction
J]W of�hc InMr Codc,fnr Nc pcRormencc of Sc work(ur which Nis pc1mii is ia�uc0.
Ca WorkeryCympe�u�ion�urenae :erPe'Puliaynu rart: ��
Sf:n1_
/'I`T�C.
CGRTIfICA'fGOPGXEM ROMWORK[RS'
COMPFNSATIONINSURANCE
(ITis ncttinn need no�he cnmpic¢�if tM1e permi�is fnrone M1unJreU Gnllars(S I(I(p
or Icss.)
1[enify tha�in�he perfoemance nf�M1e wnrk for wM1ich i�ix permii is iz�ueJ,l shall nnl
cmpiny any persnn in any manncr sn a�m Mcnmc suFjccnn @c Wnrkcri Cnmpcnsaiinn
LnwsofCalifnmia.Dam
Applicum
NOTICE TO APPUCAM':If,aficr makin6 Nie Ccnifcam of Excmpiion,you s�oWJ
Mmme auhjm io�hc Workcri Compcnviion pmvisiom of iM ISMn Calc,you muu
OO fon�wiihcnmplywiihsuchprmisionxnrihispermiis�allMdccmcdrtm4cJ.
z "" CONSTRpCf10NLENDINGAGGNCY
�-r � IhcrthyallirmNai�hcrcixecnnswninnlcnJinyagcncylnrihcperlurmanceol
6i � ihcworklnrwhlc�i�lspermitl.elssucU(Sac.3(MJ1,CIv.C.7
G] 0 Lcnticr'sNamc '
' � Isnder'sAJdmss li
V Q 1 cenify Na�I havc rceJ Nis�pplica�inn ana sum i�n Nc aCnvc info�me�iun is ',
� F rortcc�.I agmc m romply wiN all aiiy and coumy oNinanccs and stmc laws rclaiing io I
Q U puil�ingconsimciinn,antlhcm�yuulhnrixrepascnm�ivcsnf�hisciiymcmcrupnnihc i
W ulavc�mentinncJprnpertyforins�vctionpuepnscs.
� d (WU ayrtc ro saw,inJcmnify an0 kecp harmlcn i�c Ci�y of Cupcninn e6ainst
y liabilities.judgmcnu,cosum�capcnu ichmeyinanywayammcegainsisaidCiiy � 1 �..
V z inwnxqucneeufNCBnmingof ' peemii. �+ /
� APPLICANT U HRSTA AND WILL COMPI.Y WITH ALI. ON�POINT Issued by: Date � V
S URCG L TIO .
Re-roofs
i6n rc n ApplicaHAZARDOUS MATERIALS OISCLOSURE �1e Type of Roof
Will Ne applieam or fuwm LuilAinS�upam vum ur hanJlc haiaeJuus ma¢riel
az Uefi�A hy ihe Cupcnino Municipal CoJe.Chap¢r 9.12,antl Nc Hcap�anJ Safay
C�Wc.Scnion3551]�a)? All roo(s shall be ins ected rior to an roofin material bein installed.
❑r�. �w� P P Y S 8
Wip�hc npplicantm fuwre buiWing wcupam umeyuipmenl ordcviwi which If a roof is ins[alled without first obtaining an inspec[ion,I agree to remove
emii M1azarJnus nir conlaminanls af Jefined by iM1e�ay Arta Air Qualily Managemenl all new ma[erials for inspection.
DisVlfll �
❑YCS
1 huvc rcuJ Nc ha zNous mnmrials myuirtmenu unJcr Chap�cr fi95 nl Nc Califor
niullcalN65WciyCiJc Y�in yN15 �25514.IunJc�unJNoiifNchuilJing
Jres n i c my hu ¢ i, spmsihiliiy�a noufy�hc� up t nf Nc
m n mcn us� ce�taCen�nca¢ �w cy SignawreofApplieant Date
rurawhorizc�agcm n��� All roof coverings to be Class "B" orbctter