01120057 (2) OF
CITY
I BUILDING DIIVIISIONNOPERMIT CONTRACTOR INFORMATION:
BU1J,I�N'j;®LIJ[3RESSaSCENIC CL PERMIT No 01120057
1 4 APPLICA7�ON SU DATE
°'MfY Vft ROBERT W AND MARY L 12/ 14 2001
I�PHONE: SANITARY NO. CONTROL NO.
aOOARCHITECTENGINEER: BUILDING PERMIT INFO
F BLDG ELECT PLUMB MECH
Tic i V I.1 I—t C7 LJ
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D4h i LICENSED CONTRACTOR'5 DECLARATION Ob D CP IIOn
1LL n<rebrafrfmthatIamlicensedunderprovisionsol'Chaprer9faommeheing WINDOW AND DOOM RE5WEMENT/EXTERIOR LIGH
ZP, with S<cJiom 7000)of Division 3 of the Ba6ncs.and Professions Cale.ane my license
a m y-' is in fell forte and effect. -�
s s w¢ License Class
�S V Uulc --��--<]�Cnntmctnr r _
�3 u ti � �ARCIfI CT'S DF;CLARA I N - FI9i ALF 13
L 0; I understand my plans shall be used as public records o ;dvss
E
u ca
Licensed Pmfcaionnl
Oat I am BUILDER DECLARATION Contractor
JAN 1 4 2002
v�z v I hereby alrinn,oat I nm cxrnVt Imm the Comon' o License Ww for the
z> ronoxin a m'Section 031 s.t, door a and Oc de fens cues:Any coy of coumr $6800
Q grew
which rcquias a permit to amswct,ober.imnsose•remolish,or repair any stmnurt
a3o0 Msw to i¢issuance,ala re9uirts the applicant lw such pumino Ble a"JI --
- Na be
is liccnad,pursuammthe provisinm o"he"'
Jac Gnavanor s Licansc Law'ChaMer9 .�.7. valuation
(mmmenc'a wiih5<ction 7000)of DivisionJol the Business and Pmfcssions Code) ee a a,f"r
or that he fa eximpt'ho errom and the basis for'he alleged ex tro'c m.Any violaion s' c-j l -j3.Di r' a ,( < r i.1 .
-af Scnion]031.5 by any applicant for o permit subject the applieam to a civil penalty
or notmme than five nnhdred dollars(s600). 1014 PN I`#rD(lWDAT I ON Occupancy Type
❑Las ownernnnepfopenr.nrmyemPloycc.<whnwasexa,mdrwleewnpensaJon. 102 — PIERS
will do the work:and the umcture Is no,intended or offered for sale(Sec,7044, 103 - UFER
Bdviac,,and profession,Cale:The cnmrnc,oi s License Law does fen apply ,,an Required Inspections' .
0
was of propcny Who builds or'nnpmves,hacon,and who does such work himself 104 — REBAR
or eyed far
his own how...ees provided that such Impum,is rn sola within not;nmnrcr of _._ .. . . .- ..-_.. . ._.. . .. .- _ -
cBcple for sale.IL howuildr.e the building or int en of pr v n sold hedid not year or 10 5 — ANCHOR BOLTS ..
completion.the of sole.),
will have me harden of proving that he did not build or 106 — SEWER & WATER
improve for purpose orale.).
01.-as wwricor of Chi property.ran exclusively contracting with berated Contractors to 202 --' UNDERFLOOR PLUMBING_.
construct the project(sec.7644.Business and Professions Coded)The Conran ora 203 — UNDERFLOOR MECHANICAL ! '
-. - - udwhocod«sand
orsuchoanowner wthaccenrwno)Wilds oripursuavers tntothe 204 — UNDERFLOORSFRAME--
Co who contracts for such projects with a commnor(s)licensed purvuan --- — - _ --- -
GOntractor a minco'oup,codunso rdw. 205 — UNDERFLOOR. '.INSULATION
- ❑1 am exempt under Sec. .B&P C for this reawn
Owner Date301 — ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
Ihereby affirm under Penalty ofpeiuryone ofthe following decmrat;ons: 303 — ROUGH MECHANICAL
A,- f1 ❑ 1 have and will maintain a Cmifncale of Consent to self-insure for worker's 3 04 _ ROUGH ELECTRICAL
Compensation, as provided for by Section 30B or the labor code. for the 305 FRAME
_ performance of bo acral for which this permit is issued.
E)I have ad will andando worker's Compenution Insurance,as rryuired by Section 3 0 6 — HOEDOWNS
3700 of the U cw code.rw the pertormance of the work for which this Permit is 3 0 7 — INSULATION
issued. cam andisohrynurase: ,._. . 308 . — SHEETROCK -
Carrier: A �' O Policy No. C U - 0,
CERTIFICATION OF EXEMViJUN FROM WORKERS', .n ,309'•9 EX'TER'IOR, �I;ATH'
. COMPENSATION INSURANCE ".... .. .. .. .._-...... 3.1.0..../'r--I NTERI OR' 'LATH.._ ..._.._._.._--
'(This section hired not be comple¢d if the permit is for one hundred dollars 311 — SCRATCH COAT
-.313 ROOF- _NAIL
i&nrcylnaoinm=oerofm-not Of mf work for which this Permit isissued,I 501 — FINAL ELECTRICAL"7ENERGY
,hall not employ any person in any manner was to become subject to the Workers
ConnpensaBon Laws of California.Date 502 — FINAL PLUMBING ENERGY
Applicant - s -- - '-
NOTICE TOAPPLICANT:If,after making this CenificoreofExemption.yen hoold 503 — FINAL MECHANICAL ENERGY
become subject o the Worker's Compensation provisions of the Labor Cale,you most
O G Ranhwimcomply with such provisions Orthis Permit shuubed«mW revoked. 504 — _ FINAL BUILDING ENERGY
_ - _
,Z Ln "' CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL "
a1 hochy alrrm that here is aeomirucJon leading agency far me perroir ante 506 — GAS TEST -
Lender's Name, 3097.Civ.C.)
y q tud, o,`uaforwmrnthispermtisi,,uPd'soc., 507 = FINAL PLUMBING —
Addr
U O lcenrymatlnavereadmisappB<aaohand statemattheaWveihrorma,mnia 508 — FINAL MECHANICAIli
lea. f"'C.1 covdt.1 agfa to comply with all city and county ni inances cad.tato laws relating'0
0 9 — FINAL GRADE
'O mbuildinIle m:uetion.had thereby amhonmrcpfeumativuofNiscity or enter upon 510 — FINAL PLANNING
} W the above-metnioacd propcny for inspution pufpos<s.
-L. Z. (we)agrecunitive,indemnify and keep baronets the City ofCupcninoagainst 514 — FINAL PUB IC WORKS
(n Ilabilides,judgments,Ore. ad ca area which mar in any way accrue against said
U aZ City inconsequence of The granting of this permit. '
^ 'APPLICANT UNDERSTAN A OMPL VIT LL NON+PCINIT Issued by: Date
SOURCE REGULATIC VS ba O y'
Re-roofs
nature an Date
HAZARDOUS MATERIALS DISCLOSURE
WIIIns, PPlicant future occupant store or handle hazardousmnaral Type ofRoof
'.as defned by the Cupcn no Municipal Code Chapter 9.12,and the Health and Safety'
'Code,Section 25532'a)? I v . s .s e ,
❑Yes '•. ,h,.• '0No
AlAll roofs shall be Inspected prior to any roofing material being installed.,_..-. . -.
will rM1,Ji,he,a,or fare building cov.,n,int, dipmemtor devices which If a roof is installed without first obtaining an inspection;I'agree to`remove
mit hazardous air contaminants as refined by the Bay Area Air Quality Management
District? •' all new materials for inspection. Applicant understands and will comply with
y ❑Yea, - ON. all non-point source regulations. ,
I have read the hictardimsSafety
Code, m tions s uccli505.2 533 a under Chapter understand
of me
California Heahh&Safay Code,Sections 25505,2itis and 25534.(understand that
if, W kI ng d«s note ly haee a -nant.that it is my rcsponsibiliry,o notify the -
-odcupam of thcLe�ic sic nano a ma prior to issuance of Cenifcme of
0. ', O Signature of Applicant Date
.. naeaagent a - ,Date All roof coverings to be Class"B" or better
'.) - 'OFFICE - - -