00080181 (2) CITY OF CU13ERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDk ESS', PERM I'INO.
OWNIiR'S NAME: 'Al—STENDI — APPLICATION SI I
.IONH: '-0 SAN ANTONIO R SANI'ITRYNO. ^C o ( ,
O at Z ARCH'FEC'DENGINFER: BUILDING PERMFr INFO
p^l O O BLOC 121.1:(71' PLUMB MFCn
a
2u L7 1=21 I_I r_-1
man
F N u 1.10ENSEUderCONTRACTOR'S omum DECLARATION Job Description
o_G 1 M1ervM1y nttirin that 1 um licensed
under pnrvisnro of CM1,pmr J(commencing
y�
Gw wins Sccllnn]1x1111 al'Divi,ion3ofahu lluxinc„and l'udusxinnx Coda lmJ my liccuw .
m s d "in full lore as f O O
xw� a"ns. uc.a � T/0 TAR AND GRA;VEL, D SAME (4 PLY S`
On Dme_ jY/_� Cnmmemr_
5 c.G ARCHITECT"S Dit aid,r10N
u O g 1 tmdenaoJ my plan,shall he used ds public meoNco
�Y
w i O O L'menecd 1'rdes.local
e!F enI a.copsOWNER-BUILDER m the CoATION
_ I naso .(Seed that 1 am aampt from the Cmmons Co :Any
taw for the
C 7 M which
reason(Section]onstr t.aine%and ,c.danom,Cod.:Any city or county
7. ❑ M1lch I p nit t construct. Iter - p J Ilsb 1 Y amnurc
ad In or to it, IEt 1 'th ,I II h1 III,,Ii1va,i,n,d.talcnan
a.s mats licensed posaan himepno ki f he c l t r',1 . Low(Clapmr9 Sy. Ft. Floor Area af,u:Ltion
I ,n K with Section si 7") I Dn 3 f theB ae, d l f ,Cods) `J
or mut he w eacmpt fl aefmm mad the bask for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of am more than five hundred dollar,(55(4). APN Number Occupan y
❑1,ax owns,of the pul army nauployes,will,wages as their sale cooapauminn.
will do the work,and the stmcmr,is not intended or offered for sale(Sec.]IUJ,
Business and Preiressions Cale:The Conta.tor.License Law does riot apply 10 as R Dred Inspections
owner of pmpeny Who builds or improves thereon,and who docs such work himself
mmngh his own mopl,ce,provided that.such improvement,are not intended or
oma'edda,ad..u: o .the haAElng o Inpm ant N sold wimiu one y.ar of 305 — FRAME
m,mplafion,ren owner--hold,r wu1 halve me or of pricing that he did III)(build or 307 — INSULATION
pnwe to,pearpo,a of.:d..).
C3 I.a,owner of property.amca.msively contracting with licensed contractors to 601 — ROOF TEAR OFF
construct the project(Sce.]Bra.nu,mess and Pmfesxions Co,ht:) nm Contact”;s filr'li� — ROOF PLYWOOD NAIL
hLnw Joe,Ica apply to un owner nr Pnipeny who huIIJ,nr ingnm'o,thercnn,
nate who eonl,nats fon such praajacts wire a commctons)fiao.ed pursmtm In me 603 — ROOF BATTENS
Canlmnor's License l-ase.
0 lam exempt trader Sea. .B&P C rill'his reason 604 — ROOF IN—PROGRESS
Ov,m, Dare
WORKER'S COMPENSATION DECLARATION ,
I hereby affirm under penalty of perjury one of the following declarations:
,.] I have and will maintain a Certificate of Consent to-self-incom for Worker'%
Cmnpensition, as provided for by Section 37W of the Labor Coca, for the
,da..."was of m,send for which Thi,permit Ix iIlmd. .
�haman
rive and will maintain WarIe,',Compemelon Innumnce,as ma,eired by Section
UI of the labor Cale.far the perforce of the work for which this permit is
i,.med.My�WnrkL 'CC(p p%ensl tion Insurance carrier and Policy mmoMr are:
Cnrriur._�z[/t�Ltt_�'�Kl-Policy Nab 7-/=9_9-iii
CEIf1'1171CSFION 0I7 EXI7MI'T'I FROM WORKERS -
COMPENSATION INSURANCE
I Has section need not M completed if the Pamir is for one hundred dollars
($bb nr le"')
1 clan,than in the periima noo of the work lot whl,h tins iarnit i,Esucd.I
,hull nm.mp1oY any perom in any manner m as in become.subject In the Workers'
Compensation Iain of California.Dae
Applicant .
NOTICE rO APPLICANT.If,after making this C.mpaae of Eacntption,you do"IJ
baanln.1 hj..t ti.the Wold,Cmnpen,aion puI'loo x Ill 1111 Labl Code,'no Inne1
O fnahwlll,comply is uh such pa.vi,ion,or Iii,permit shall be devoted revoked.
Z —
f" rn CONSTRUCTION LENDING AGENCY
a ? I hereby offml that mem mss (S
amsd mleading agency for me performance
If IM work fur which Ibis pcnnit is IxwlcJ(Sm.11197.Civ.C.)
G Lander',
Name
.ti. Z Ixmdcr's AJJm„
U 0 1 mrify that 1 have ad this application unJ.mm that the adore information is
4 L• correct.I.gree no comply with all city and county ordinonee,and nate I..muting
C IJ Ill buildin,comarowtian.wtd batch,landimm reprc%entatives of this city to enter upon
t� W the"hnvc.mcnlln"d m p,ny k .....cell..purpa.cx, -
. M. (We)d,ma o"oave.indemnify and keep hwml...the Clry, It Cupcnino agolut
y liabilities.judgments,coa.c and expense.,which may in any way.,me against said
U Z City in adownquenceofthe gaming of this pc e
AI'PLICANTUNDNDBR COSTAND WILL COMPI 'WITH ALL NO POIF/rr Issued by: Date
SOURCE REGULATIONS(
Signnwm of Applic:mVGmtmnur — —II(Dale Re-roofs -
HAZARDOUS M ERIALS DISCLOSURE
Wdl the applicant or future Wilding occuNnt store or handle Wourdous nuterial Type of Roof
fe defraud by the Callo inti Municipal Calc Chapter 9,12. ad the Health and Safety
Code.Section 25512(,14
0 Ye, ILgif,' All roofs shall be inspected prior to any pooling material being installed.
Wiit the applicant or future Wilding occupant ow equipment or devicc,which If a root is installed without first obtaining an inspection. I agree to remove
nit haamous air contaminants as defined by the Bay Area Air Quality Management
;siricl, all new materials for inspection. Applicant understands and will comply with
OYe, L:14� all non-point source regulations.
OLI have mvA the huzumum nwmriulc nyuimn¢nP under Chopter fi 95 nl meia health&Safety Code.Sections 255(15.25533 and 25534.1 undersand that /'ilding docs not eurenoy have a tenant,that it is my re,pmsihilily to notify the /-'r 00
of th.regnimmm�u which nod he nmf prior to i,wSignature ofA icant Date
r.tm, i, All roof coverings to be Class "B" or better
OFFICE