01030020 (2)CITY OF CUPF:RTINO
CONTRACTOR INFORMATION:
auu.DING DIVISION PERMIT
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I1'f:RMIrNnaNG M C Co ! 5 r
WNER'S NAME:
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APPLICATIONSIJIbIMT�OF�2001
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SANITARY NO. CONTROL NO.
A CHITEC'VINGINEER:
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BUILDING PERMII INFO
BLDG ELUMB 1
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LICENSED CONTRACTOR'S DECLARATION
Job Description
herchy affirmthus Iran IieemoJ under provisions of Chapter 1)(cammareing
with Saaiet0 700(nal I;i1iOoo 3 of the Baine., and Nefc,sion, Code. ane my hccttse
ADDITION.
I.in fall fans and effe O �•j L
icrnsc Clu,n_� Lic.p� If; C/
Dae
S DECLnr
A,dial ECI"S r10N
e, puARA
I unJccawA my plum xhull In� umA us public rcconlx
Lire...cn rrote,.io;,;d
OWNER-BUILDER UIiC1.ARATIDN
1 hereby affirm that I am exciap, from the Contractor', License "a% for the
following m:mm. (Section 7011.5. B.,aa,,;a d pool k2cion, Cndc: Any city ser county
which rtgaim, a proton a Construct. cher. improve. demon,n, or repair any sbacture
-
pilar to it, mo,mer, aEe retire, the applicant for such pamtit m File a signed statement
Sq. Ft. Floor Area
VaI 11
QIo
,barheis nemed pmuan, it theprov,hits of me Comraun', Li craw ww(Chapter o
(commencing with Section 7,001 of nivi,ion Sof the Insines, and Profm,iom Cde)
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or that he is r,enlpl Iharetmtn and the htn'iv fou the alleged exemption. Any violation
of Smoot 7031.5 by any applicant for a war it .subjects the applicant to a civil penally
,if aetname Onnrtvehundredao0urs(a50o).
APN[ Ise TbO14.00
Occupancy Type
0 L as owner of the property. or my cmplorec, with wage, as their ram compensation.
— ��C.(p�tt�y��yyq!-1ry.,,,�n,�jCt10D5
101 F V V IVLA I L UI
will do ,he work, and the structure i, it(In¢ndeal or indexed fur sale (Sec 70,14,
Bu,iness and Pmfe„iun, Code: Thr Con,rsmr's Liceme Inv, does nm apply to an
of property Who builds, improves thereon• and who J,es such work himwlf
orvthrough hI. own a iployces.'piovided mal such impmvemmiom are 1101 Imrnded or
J02 — PIERS
olTcrd for sale. IL howavec,he building or improvement i, old within one year of
i�nnplcdnn,maowner_hr;lee,wlIItroche har&rafpro,mgmmbraid notbendor
103 — UFER
nproae n,rpmq„e er,ulr.). .
104 — REBAR
0 L a, ownt—I da pro,hys stn c,cot,ivcly carouic ing with liecn.w contractur, it,
be rmja,t (see. 7(A4. Baine,, and Prof,„inn, Code:)The Comremr,
105 — ANCHOR BOLTS
Linstruct
iao, Law does not apply mann o Oar of property woo hold, or in,provex'hereon,
and whe commit, or,rich prof«t, with a tour clonal licensed pur,ant m ror
1.06 — SEWER 8WATER
r-ourrtti License Law.
❑lon, mamp,under See. .n,vPCfor lots reason
202 — UNDERFLOOR PLUMBING
O,m, Datr
203 — UNDERFLOOR MECHANICAL_
WORKER'S COMPENSAI ON DECLARATION
204 — UNDERFLOOR'FRAME
m..a yo l 1 gone„
I head,afnna,tntmr h I,mm Ilse toll—in, drewraean,:
205 — UNDERFLOOR INSULATION
❑ 1 Iwvr and w;II trtam,mn a eby eat of (bn,ein meaLabor far warkthe
Cntnpenmtlon, tv provided fur by tice,inn 371N1 of the Labor Cndc, lilt the
v
301 — ROUGH PLUMBING
,achumawconhrwa hu,hich,m,pemnti,i„arJ.
302 — TUB B OR SHOWER
01 have and will maintain W'ader's Cotnprmaion Insurance. a, tryuired by Section
303 — ROUGH MECHANICAL
3700 or the labor Cade, for the performance ar the work for which this permit is
i,saes.MyWorkers Cotttl asationInsurance carrier and Policy number are :
304 — ROUGH ELECTRICAL_
Carrie: Policy NO
CERT IFIcmoN OF r,xehda[ON FROM WORKERS
305 — FRAME
COMPENSSrION INSURANCE
`
306 — HOLDOWNS
(ni„ection total not be complated if the penny is mount, hundred dollars
'307 — INSULATION
O l Nu or
308 — SHEET ROCK
I certify bar in he perrotmanee of work for which thin permit is issued.1
-
,huh n,a cotptoyany Fiat,.... in ,toy..tanner se .,a to beeome,nhjat,o the Workers
k 309 — EXTERIOR LATH
n,ntTTaim{ lawx y cdaomia. nae
pplie:tnt `
310 — INTERIOR LATH
A�_j1L
Gner:Tu Fitt.eWoroa's
Com,nakmgn,ire'eniha,ron+,cmp Cda,ou mum
become snMcumror worker, Compensamrn pnw;,mns of me laM,r rade. rose must
311 — SCRATCH COAT
fonhwim al ply with such fauvist aoso, his permit hill he dra n,d revoked.
313 — ROOF NAIL
C(1NS'I RUCNON LENDING AGENCY
1 herchy anion mat there is a cm„Imclum Iaodiog agency ter the parlor..umc
501 — FINAL ELECTRICAL ENERGY
,if he work let which this pcmm is issued (Sec 3097. Ci, C.)
Icumr, Nate
” 502 — FINAL PLUMBING ENERGY
I.entire', Andres,
503 — FINAL MECHANICAL ENERGY
I eerily that IIta,,rrudda, uppEcnro,n anti ,m,, lea me a bet, immuatlmt is
correct I agree to comply with all city and county ordinances and state law, ranting
504 — FINAL BUILDING ENERGY
to houldfin,onansoi t told hyo hd p i e,enn. 'y, care, attain
the aro eee,npane p r .
505 — FINRL ELECTR CAIr(e-
) g h-avindemnify andk p harroic, he City ofc pen asa,n,t
ay-
5 — GAS TEST
nubur:jdg Pct, a , xwln Joy w) mitt,asaid
City to consequence of the graining of this at
kq j�,1,
Issued by: 09W /4 -�9MI ate
SOURCE•1{M�[f(�UNI)17RSNSNUSANDWII.I.COMPLYWITHALNON-11f�
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uwrc fd Aypli u..t/Co..nacmr )am
HALARUOUS MATER1AI-S DISCLOSURE
Re-roofs
1509 — FINAL GRADE
Will ,hr applicant or (inure huilding ne,cen, store lir handle hanN..... mmcriul
Type of Roof
YP 51.0 — FINAL PLANNING
adenncd bythe Capemmn Manieipil C,de ClesoOa.12, surd the Deahh and Seto,
Code, Section 25532u):1
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All roofs shallbeir�s ecTcd p�i�ii Jr�i�e�rr l-rn i ing installed.
Will tneappliaametfuture haildiog,.eup:aarove claimant, device, which
If a roof is installed without first obtaining an inspection, I agree to remove
harardo., air auntantinums lO defined by ,he Bay Arca Air Qmdhy Mawgetnci t
mmol��
km
all new materials for inspection. Applicant understands and will comply with
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all non-point source regulations.
I l,:ne read the hmanlous material, requirements under Chapter 645 of the
Cali4lm s Health di Slay Cndc. !barons 25505. 25537 and 25534. I undct'slmal Ibal
If the building does not cunen,ly have a reliant, that i, is my msp,m,ibili,y to unity the
eer,Pam ul ror re�lretuunl, which nw.I rte mal ror In isxunnre nl a eni0caw of
cit.pant,
Signature of Applicant Date
tom'
All roof coverings to be Class `B” or better
O m U c
OFFICE
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