01050165 (2) CITY OF CU13ERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BD I LDING ADI)It CSS: PERMIT NO,
OWN'EMS NAM::O521 APPI,ICAl ION SUB DATIi
IIONE: KIRTI %AHBABE ' A61 PF_=RP-YI49NT-,
SANn'ARY NO. - CON'IRW,NO.
OM ieO ARCHI IECDENGINFER: 'r' BUILDING PERMII'IN[0
qq BLDG ELECT PLUMB MECH
FGW 1=1 I_I I_I IJ
�,`�� LlcltNsr:ncoN'rlencn>R•sDECLnnm'B)ry Job Description
I hcmby aflimulmt 1 am lucemed under pmrviniono of Chapter 9(commencing
OyFo with Section]I00B of Diviaio 3nflM1e lmmucsxand Pmfcesiom Codeand myliceme
<Yt3 Ix in full lura nnJhd. /•
�ei Lmemecl aU G� Ca.N U _ REPLACE EXISTING- CQNDENSINGrUNIT' WITH
a Dat.�r� p 2 S DECLARATION
( nncurrP;C'Ise m,uhh Aev 1 CONDENSING OMIT SAME SIZE.
1 undcr%rxnJ my pions shall M used as pnhlic nennls
eWaS.
ti 6 p O I,iacnscd I'rnlcu.,inn:,l
OWNER-RUILDER DECLARATION
J=H 1 hereby all,.that 1 um escmpt from the Commnar\Licenu Law for the
F, ¢ fullowing repo m (Section 7031 5,Hwinova and Pmfcmimns Gale:Any city or annoy
4 2 C which requires a ry_nnil m comm,.,idler•improve demolish,or repair any structure
prior to its issuance.alma requires the applicant for such permit o file a signed emtemem
thin he ixracmedlanuantmfire room ooftheContractor,LicxnaLe.(Chapter 9 Sq. FL Floor Area Valuation
(commencing with Section 710(11 of Division 301 the Ituomce s unit Pr ic%oons Code)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
,it Semen]031,5 by any appfic; t h„a permit slmjec,,the applicant Ina civil renally
,if muniore than five llntmred dour,01531). APN Number . Occup a�cy Tyllfr
El 1,mownerul tire is two,or toy cinployec%wan wages as theirsoleenmpensatlnn. 1+1 b
will do roe wok,and(lie etrucmrc is inn intended or offered for sale(sec.]IWq, R fid Inspections
Business and Professions Cale m The Contractor's Lice" Law does not apply to an p
of property Who builds or impoocs thereon,and who inks such work himaH 32G48034. 1 rens
n.thenugh his own employers.provided that Inch improver ems are inn imenJed or
olrcred for We.If however.the building or inhpmerinc o is sold within one year of
mmplcliun,the owner-builder%ill have the burden of proving that he did not build or 204 --'UNDERFLOOR FRAME:,.:
mprawn for pnrpo.c of mite.),
C3 1, he property.amexcwxivcdycontracting winhueemcdromernr 301 — ROUGH PLUMBING
Lconstruct three vn+jeca(nee.]Iwo,I+minem and PmE„xiaas Codn..)'I the Contractor ,s 03- — ROUGH MECHANICAL
iceme law does not apply to un owner of Proprny who builds o,impone,ohms.
an contracts for such prm
oject%with a contemm rts)licensed pursuant the 304.
cmmm�msu
xl "n,l.a,%,. - — .ROUGH F_I_ECTRICRL.
❑I am exempt under Sec. .11.@ P C for this reams 505 r.• FINAL--51LECTR-ICAL ,
owner Date 507FINAL PLUMBING . . ,
WORKER'S COMPENSAI[ON DECLARATION
nmreny Wim,soler pe.ally of perjury nor oche fofideclnrathmx: 508. — FINAL MECHANICAL+
O 1 have and win maintain a Certificate of Consent to elf-insure for workers .914 — FJNAL PUBLIC WORI(S
Compatwlion, is movidca lur by Sari... 37N) of be Iain„ Cede. Iia the
perlonnunce of Ise work fur uhieh this permit in rowed.
❑1 hmu;nW will maimn'a Wurwr's Co air,—L ion hionance• is inquired by Section I
3700 of the Lobar Cldc, ,the pedurnana of the work for which this permit is
issued.10,W..ker's Conti`main.Insurance sari ..an'd Policy nuUmber am:
oo
Camcr:C _CI:HTIFICA'fIOIt ) -\fi�Nl'1'ION bR(l\ KERS*
COMPI7NSNI'ION INSURANCE FIN ALE D
(This.action need not be completed if the permit is for one hundred dollars
(slaq,aU,%.) MAY 2 3 2001 .
1 cenify than in the performance of the work Ior which this permit is loved.1
shall not enghloy any person in any mmuner so a%to IwcOme subject m the Worker:
Comic ion haws of Cadilnmia.Uric
No TI`17 BUILDING
NOTICIi TO APPLICANT 11:miler making this Cenilicutc nt lixemption,you should
ba aane subject to the Worker's Compranvo ( isio
prevno
s f the Labor Code,you amm
Qforth.ith comply with such provisions or this permit shall he Jared revoked.
FVi CONSIRUC'I']ON 1.17NDING AGENCY
Yi > 1 hereby ufrom thin there is a enmwction lending agency for the pufomu ee
of me wok for which his permit is issued(Sec.3097,Ci,C.)
Q (,eater's Nano
D Z Lender's Address
C.) (:) 1 cenify that 1 h:.c end fill,upplicur J(:uN stwc(hot the nbnvc iamrmairn
F In
kg. u inn.I agree m<onmplwith all airy an Bounty nNinanccs and stat lows relining
Q C.7 u+building enmtmclin nit hereby unlit lie representatives ofthi.s citym enter upon
} �] the obnve-numinncr ,I�� tyli+rInyw 'G I purpose,,
E,. 6. (N's)agere vitt inJI, ify keep harmless the Cllyof Cupenino against
h Iiubilitics•jail .costs and e s which may in any way acme against said
J 7 Cay in a ,a4u h of the nh leis perudt. �� '�-2 2� Q
APPLI ,A FIRST WILL COMPLY WITH ALL NON-POINT Issued by: Date
.OU C 1 1LATI0. y'
. sig a ..1 ApplicsnUCommctm Dale Re-roofs
I IAZARDOUS NIAl'ERIALS DISCLOSURF.
Willtee onprte.an ornnhrc4 mdldingocrhlpaol.lore ornaodlr eaanmmtl,n:nedld 'Type of Roof
¢c derma M1Y lea Cupcnino Municipal Cole,ChuPter 4.12,ane moa tlemm ane Sidely
Cole,Senum 25532(a)I
o vex Cl No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device%which If a roof is installed without first obtaining an inspection, I agree to remove
inn haaardous all rouwminunrx ns Acnnud by dm 11ny Area Air Qaalhy M;nmi anon
D.Nallr all new materials for inspection. Applicant understands and will comply with
❑Yes ❑N.' all non-point Source regulations.
.1 have natjTI e hvhnlnus marc Is n'yuimnuvm under chanter n.')5 nl the
California Hcahty8'Sulcty Clnlc.Sc a,255115.25533 and 25571 unJcmm�d red
'fine buildingA nt currcnByh 'tcnun61hal I"my rer.....I ilhy to notify the
«cupan tl wh' 1 use be mer Prior m(mucus of a C"lilieu a of
en Signature of Applicant Date
or m.raedagenl Dale All roof coverings to be Class "B+'or better
OFFICE