03010163 (4) a CITY OF CUPER'I'INO '0y
BUILDING DIVISIONNTIkCTO
PERMIT CO RINFORMATI"AiON:
4 BUILDING ADDRESS: PERMIT NO.
OWNERS NAME: APPLICATI B A ;
IF
ONE: SANITARY OL NO.
ARCIIIIIiC / BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
eiLICENSED CONTRACTOR'SDECLARATION
tt U F 1 hereby affirm that 1 am licensed under provisions of Cbapmr 9(cnmmennng Ob Description
Ci6n with ]aXp of Div sign lof NC BusinCy(xnJ Pmfcxsions CnJc.coil myliccnse is
CZ—O DalealswContracmo
s"vr F-w RCIIITECI'StD ARATI N /
n< tend my plans shall M rood puNic records
uSis
d u Licenwd Prolessiawl
X'p'O� OWNER BUILDER DECLARATION
Ot
rti a I 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i 00 following reason(Section]BJ 1.5,Business and Professinnx Code:Any city in comm}
K$0� which requires a Permit to construct,alter,improve,demolish,or repair any structure
ad
prior to its issuance.also Inquires the applicant forsuch Permian file a signed statement
TEGthat he is licensed pursuant to provisions of the Convaewr•s License Law(Chaffer 9 Sq. Ft. Floor Area Valuation
at
el— (commencing wi isSection 7000 of Division J of the Busi ness and Prnfessinns Code)or
y F$ Nat he is exempt therefrom and the basis for the alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applicant)a civil penalty of APN Number
not marc than Bve hundred dollars ak!C(d. Occupancy Type
❑ I.as owner of Ne properly,Or my employees with wages as their sole compensation.
will do the work,and the structure is not intended or offered for sale(Sec.](N6,Business
and Professions Code:The Contractor's License law does not apply to an owner of Required Inspections
property who builds or improves Thereon,and who does such work himself Lir through his
own employees,provided IMI such impoWemenB art not intended or offered for salt.If.
Mnvever,the building or improvement is sold within ane year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
Safe)
❑1,as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7064,Business and Professions Code:)The Conuactor's Li-
cense law does,not apply m an owner of property who builds or improves thereon,and
who comment for such projects with a contranm(s)licensed pursuant m Ne Contractor's
License Law.
❑I am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby anion under penalty of perjury one of the following declarations:
I have and will maintain a Cenificare of Consent to self home((it Worker's Compen-
7C�E'
tion,ss provided for by Section BA()of the tabor Code,for the performvtee of the
W
for which Nis From it is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
1Nh,f the bur COJe.for the pe do cco(the work for which this permit isissucJ.
ork r� n naalit sumo dPolicy umberamrries omrPolicY
CERTIFICATE Op EXEM PITON FROM WORKERS'
COMPENSATION INSURANCE
(This section seed not M completed if the permit is((it one hundred dollars o 1 W)
or less)
1 ecnify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner m as to become subject n the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:It;after making this Cenilicam of Exemption,you should
become subject to the worker's Compensation Prov sions of the labor Code,you must
O z forthwith comply with such provisions nr this permit shall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[-+ l verity affirm for there is a construction lending agency Bn the performance of
ai the work for which this hermit is issued(Sac.3097,Civ.C.)
4 Q Lender'sName /I
= z
L) 1Lendcr;c Address
p 1 ecnify that 1 have read Thirty and coup and sum Thal the anve information is
CH roncn.lagrccmComply
and With
yarmuaod eounryhmati s of and sole laws chair
har upon the QU above mentioned
gm,cnd herebyorprpuses,nutivcs of this city mcn¢rurym the
r W aMvrmcmidgm propc costs
for inspector es purposes.
y (We,agree to save,indemnify and trey hadmlesv the City of Cupcnino against / r S
liabilitics,judgmcnu,ensu andcspcnscs which may in any way attry ogainr said Cny (L
V z in copLwnceU of the gmming of thipermit.APPNDERSTANDS AND WILL COMPLY W II L NON-POINT Issued by: Date
GULATIONS. _S4
Signamrc ic
of Applican antracmr
'e-roofs
IIAZARDOR US MATERIALS DISCLOSURE """Id
Type of Roof
Will the applicant or future building occupied smrc or handle hvsuJuus material
as defgvd by Ole CuPeninu Meme al Cade.Chapter 9.12.and the Health and Safety
.nils.Semon p5532(a)/ �f
p yea LS No All roofs shall be inspected prior to any roofing material being installed.
Will tncapplicant Orfuture building occupant u.seequipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
nil haa.alloux a ireanmmmanLc av defined by the Bay Area Air Quality Managcmenl all new materials for inspection.
Uis"le"
❑yes
I have mad Ilse MiaNuuemalcrials mquiremenu undcrCMpkr6.95 some Calder-
niaHealth&Safety CtW.S 6ons2551)5.255BBaod255.o I mkimamlthmifthebuilding
Jlws •ally have a Tenant.Nal it is my resryt ibiliry o reufy IM txroupant of the '
he swhichmussbemcl pdnao issuance of Cc Icam Of acupancy.
y Signature of Applicant Date
r
ow autharimd agent Dale All roof coverings to be Class "B" or better