02110047 (2) CITY OF CUPEWI'INO °' � .
BUILDING DNISION PERMIT 'CONTRACTOR'INFORMATION:
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iON17. — SANITARY NO. CONTROL NO.
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ARCHITECfIENGINEER: BUILDING PERMIT INFO
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BLDG ELECT PLUMB MP.CH
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POO LICENSED CONTRACTOR'S DECLARATION
�SoGn Iherebyaflir- ha,lam licensed audit,provkiomofChap¢r9(commencing REPLACE WATER ' � i1lon
w ith Section 7AXdr10 Division Sof NC Baxinessand Professions CiOmmadmylibemcis p�
�xs
full fume and effect. (4 0 GALLON GAS) ��p
Czz License Class Lic.• ED
—p Date Contractor
F=�d,J' ARCI lln- I"S DF,CLARAI'[ON
�0�a I understand my plans shall be used as Public recnNs MAY 0 2 2003
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w 3 u.r LittnwJ Prnfcssionm
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OWNER-BUILDER DECLARATION
I hcrchy affirm Thal I am cxcmp,from the Cuntnctor's Lidcnsc law]iu the WILD
w�p O following reason.(Section 0(131.5,Business and Professions Coale:Any city o,county
X m(L which requires a penrh to construct,alter,improve,demohsh,err repair any xlruem e
ca—vi Pnnnn its issuance.also,Moires the applicant for such perminn file a signed statement
S< that he is licensed purmammNepmnsionsOftheCumracmr:sLicense Law(Chapmr9 Sy. Ft. Floor Area Valuation
al—$ (commencing with Se,rion7XXHofDivision3it the Business and PmfcsxionsCode)Or 31641060 . 00
y 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 to a civil pmahy of APN Number Occupancy Type
no, me than I,.hundred dollars(s5m). 502 - FINAL PLUMBS G ENERGY
❑ I,as owner of the property.rt my employees with wages as their Side compensation,
will do the work,and the structure is not intended or offered for sale(sea 71164,Business
and Pefcssions Code:no Conmcels Limnz law does not apply a an own,,of 507 - FINAL 4jJKj�I}l1@$ections
poi who builds or improves thereon,end who dmaxisch work himself or through his
ownemployces.provided that such improvements arc not ina,med or offered for Mle.If.
however,She Wilding or improvement is mild within one year of completion.the owner
builder will have the burden of proving that he did not Wild or improve for pu Pase of
salt.).
L as owner Of the property,am exclusively connecting With licensed contractors to
consumer the peace,(Sec.7044.Busineor and professions Code:)Tho Conmcer's Li
wort,Law Jens no,apply to an owner of progeny who Wilda or improves thereon,and
who contracts for such projecu with a commcmr(s)licensed pursuanun the Contractor's
Lice se law.
1 am exempt under Sec. B&P C for this Maxon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury One of the following declarations:
I have and will maintain a Ccni ficate of Consent o self insure for Worker's Compcn-
Miion,as Provided for by Section 3700 of the Iraner Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as mquimd by Section
3788 of the LAWr Code,for the performance of the work for which this Permit is issued.
My Workers Compensation Insurance easier and Policy number am:
Cartier: Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section road sol W eomplcmd if,W permit is for one hundred dollars(g10)
our less.)
I Benny that in the perfnonnrce of the work for which this perm i,is issued,I shall nm
employ any Person inany manner ar,as in Wcume subject In the Workers'Compertsmion
Laws of CaliforniaDate
Applicant
NOTICE TO APPLICANT:11,after making this Craft icam n1Exemption,you should
become subject to the Workers Compensation provisions ofthe labor Code,you moot
OO forthwith comply with Such provisions of this Permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
IWrtby affirm Na,there is a cnnsuachon lending agency for the performance of
Sin the work for which this permit is issued(Sec.3097,Civ.C.)
W� 0 Lender's Name
ISWcr'I Address
U. 0 I cmify Na,1 have real thirty and county
and sem that the above information is
W H bonding I ogmc a comply with all city and cuumy ordinmcca and mans laws rrelatingupto
V building pen,and
ty` in,echimiLerepresenm,ives of this city it)enter upon the
Show
6. (We)agree to cove.indemnifyexpenses
and keep hay in an w City a Cu must against
SUN
liabilities,judgments,e granting
uind Of this Ps
mit. mayinanywayaccrvc against Mid City
Uz incursCANITcof UNDERSTANDS
of thNDWit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature err ApplicaHDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will fire eCuPentnr futurebuildingooccupantyoreor handle Awardnusmamdal
As Jcf neJ by,W Cupcninn Municipal Code.Chapter 9.12.and the Ilcahh and Safely
AmLcodr.
-.u,
❑Nn All roofs shall be inspected prior to any roofing material being installed.
s
Will the applicant nr fmure building wc.pan(use oyvipmcnl err devices which If a roof is installed without first obtaining an inspection, I agree to remove
limit haaardous air conmminams as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
1 have mail the h2vardous materials requirements under Chapter 6,95 of do Califor
nia I sealth&Safety Code,Sections 25505,25533 and 255341 undemmnd Out if the Wilding
docs nm emmnny have a mmael.thin it is my nexpmsibility in notify the dccupam or the
mquimmenta which mum be met prior to issuarce of a certificate ofoccupancy. Signature of Applicant Date
Gamin,ao@mived agent Date All roof coverings to be Class "B" or better