03010037 (2) CITY OFCUPEWHNO a.�y ,• °� -r'z
BUILDING DIVISION PERMIT CONTRACT,OR�INFORM"ION
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO.
10161 PHAR LAP DR 010037
OWNER'S NAMIi: 970 E. MAIN ST, SUITE 200 APPLICATION SUB DATE
THOMAS JEFFREY A AND MARY L 01/07/2003
IIONE: (415) 566-2209 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINf:ER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
rOp LICENSED CONTRACTOR'S DECLARATION
e1r U I hereby affirm that 1 am licensed Carter provisions of Chapter 9(commencing Job Description
whh scnion 7agB kir Dmmion 3 nrthe eaamea..ad Prnreaainna cmc,ane my Rcense is
� „ inmIfineeander .�� -3 X73 REPLACE WATER HEATER
Z license Class Lie.N
O Z�O Da¢ o Contractor
6`��'�' ARCHITECTS DECL ATID FU NdALE93
CF nm
0 6 u I understand my plans shall he Cord as public rcntNs
t3+.
-a
LiccnscJ Professional JUN 1 9 2003
Cy— OWNER-BUILDER DECLARATION
B<Y 1 herchy offrm that I am exempt from the Contractor's License Low for the
a S 00 following reason.(Section AD 1.4 Business and Professions Cmc:Any city or county
$ which requires a permit to construct,alter.improve,demolish.kir mpair any structure
prior to its issuance,also requires the applicant l nrsuch permiun life a signed statement BUILging
sa
that he is licensed pursuant it)the pmvisinns of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Ion
FO (com menti ng with Section 7000)of Divisioo 3 of the B usi ness and Prifesainas Cnde)or
y $ that he is exempt therefrom and Ne hasis for the alleged exemption.Any violation of
Section 703 t,5 by any applicant for a permit xuhjecls the applicant n a civil penalty of
not more than five hundred dollars(f500). bC Occupancy Type
❑1,as owner of the pmpeny,kir my employees with wages as their sole compensation,
will do the work,and the structum is not intended kir offered(or aile(Sec.711,4,Business 582 FINAL
and Professions Code:The Convenors Liecnse Law docs not apply to an owner of 5 0 6 - GAS TE uire nspec Ions
property who builds or improves thereon,and who does such work himself kir through his
Own employe,s,provided that such impnevements am no,intended or offered for We.If, 507 — FINAL PLUMBING
li.evm,the building kir improvement is sold within one year of completion,the owner.
builder will have Ne human of proving thm he did not Wild or improve for purpose of
safe.).
❑ I,as owner of the propony,em exclusively cantncting with litems,Com mon.to --
construct the project(Sec.71/44,Business and Professions CMc:)The Contractors Li-
cense Law does not apply in an owner of property who Wilds or impmvea themon,ane
who contracts for such projects wish a contractor(s)licensed pursuant o the Contractors
License LBW.
❑I an exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I herchy M.under penalty o(pedo,one of Ne following denlarouros:
1 ban and will maintain a Ccnincme n(Consenun sebrinaum for Workers Cnmpen-
salion,as provided for by Section 37011 of the Labor Code.for the performance of the
work for which this pit is issued.
how and will maintain Worker's Compensation Insurance,as required by Section
W of the labor Civic,(kir the performance of the work for which this permit is issued.
y Wnrke' satin Insurance,aoieranJ Policy yu�herare: — Z
Canicn�= %aS Polibl
CERTIFICATE rEXEMPfION PROM WORKERS'
COMPENSATION INSURANCE
(This section need not W cnmpfered if the permit is Foonc hundred dollars aIdin
or less.
1 cenify that in the perfnmmnw of the work lir which this permit is issued,I shall not
employ any peham in any manner ski as to t ocnmc mh,lecl to the Workers'Compensation
Laws of CaLfnmin Calc
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicate of Exemption,you should
become.subject to the Worker's Compensation provisions of the Labor Code,you mus(
O O forthwith comply with such provisions or this permit shall he deemed revoked.
z "' CONSTRUCTION LENDING AGENCY
a .N. I hereby anion that there is a cnnmmc(ion lending agency f naive Performance of
r7
the work far which this permit is issued(Sec.3ND,Civ.C.)
V4 Q Lemcr's Nam,
z Lender's Address
U 0 1 cenify that l have read this application and shote that the above information is
LG F correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building constmction,and hereby authonm mpresenhofives(i(this city to enter upon the
r abnvoontrumned propeny for impemian purposes.
(We)agree to save,indemnify and keep harmless the City of Cupci ins,against
F y liabilities,judgments,cora and capenses which may in any way accede against said City
U Z in consequence of the grand ng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON POINT Issued by: Date (422
SOURCE REGULATIONS.
Re-roofs
Signature of Applican iContractor
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or furore building cecupam stare or handle hasardous material
as defined try the CUTcnino Municipal Cmc,Chapter 1.11.and the Health and Safety
core.Scmien zss74(a'! ��. All roofs shall be inspected prior to any roofing material being installed,
❑Ycs
Will The applicant or!more building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit hazardous air contaminants as defined by the flay Area Air Quality Management all new materials for inspection.
DistriO7 �>
❑Yes 5A`
1 have read the haramnus mmeriafs requirements kinder Chapter fi 95 of the Califor-
nia llmdth&Solcty Cmc.Sa(inns 495115,25537 wd 45534.1 undemmnd thm if the building
does not cuocndy hove mod.drat a is my resp risibility to notify the Occupant of the
mqulremems vel" xtM ort prinnn i, once ofa Cenifcatecf Gcaup 'y) Signature of Applicant Date
,%nerorauthori,edag, „eV All roof coverings to be Class"B" or better