00090004 (2) CITY OF CU13ERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
s,kll11LDING ADDRCSS' Cx-rc p�GGTiONS I'IiltMl'I'No,
G 'I 00090004
OWNER S X4.1032. TUSCANY PL /� �2� e$Iv /TL4 4✓2 APPLICATION SUB DATE
' a9/01/2000
SANHARY NO. CONTROL NU,
ROSSMAN blAl_TER A AND NAR 052 C+ 9'j
C K Z ARCIII I IiCUENGININX BUILDING 1117RNII'I IN[O
w p$ — 3JI — /L 33
Lp<' HLECr PLUMB MECH
N¢a t ' J CI l� IJ
dH Z LICENSED CDNIRACIOR'S DECLARATION
ye I hereby drmldial l ambceawd ander post Cavv otChapter 9 commencing r./0 rL�Y� I.JSOo1��K� Job Description
FZCw lhS r '!1X181 IU 1 f1 Ito.- II' f lost Cuh.til nY!cense ! /'I
x� U Icafillrsan, d " G � La « ?"it-/03S INSTALL 30LB POUND FELT, 13 SQUARES OF
LLO ClVis-la ARCHITECT eDECL� •A ' PLUS SHAKE "B"
we4 1 understand my Plans sM1ull he lived as pu d, I'( 'VCS
so i C Licen,cl I'rnfe,,innal _
OWNER-BUILDER DECLARATION
e un m 1 Leahy off nn mm 1 am esmnpt fmm the Cnmrvcmr'x License Ww for the
h Z fallowing maser.(Section 703L5,Businessland]Profexaiom Cade:Any city or county
Z_
❑ which requires a permit h1 construct.liner,improve,demolish,or repair any strudam
pr rztt lko he pixandf h planart file.signedLtmnlem
has is la,ennedpanorand In site 1 f he Cool License Law(Ch.,,,,9 Sy. Ft. Floor Area Valuation
(comms tang with Second 9001)of Division i of the Ifo,nus old I s sessions n.Code) vv pp
or that he is exempt slumbrous and the basis for the alleged exemption.Any violation '•3 5 VAP_vJ 1 59.
of Section 7031.5 by any i,rd com fora permit subjects the applicant lua civil penalty
aflotlmlm than fie hunmea dollars(55O), y AIIN NumberOccupandyE7js(ie9
01,as ower of the proireny.or isiyedy,loyeoswlm wngexas me'�rsomsomp.....de, JS — 2- _ 092- SIP—
will Jo the work,and the stmcmre is not intended or oflcad for idle(Sec 704x.
Business and Professions Care:The Commremr's License Law doe,dot apply to an 3592904 Lip4uj?red Inspections
ncr of prupeny Who builds or impmvev thereon.and who Jae,,such work himself
Or through his own employees.provided that such supnwenoms are not intended or
offend far sale.11,howeverthe bidding or improvement is wld within one rear of
ampleour,meowdor.brdldir, 111 woe ale ha dei of prd,i t,mat he
did dot build or 305 — FRAME
improve for pdrpo,rof salt', - 307 — INSULATION
❑l.as owner othe pmpertr.amesclusivdycontracting•imlicensed contmemr.it) 601 — ROOF TEAR OFF
L ,metmthe project(Sere.7041 Business cad Precision,Code:)me Carper
icense Law does not apply to do owner of property woo mods or iroprores thereon. 6x2 — ROOF PL-YI400D NAIL
acnd who mnac(v for such projects with a ulnmetods) Teen erl pu sunt m the
ddtramor uaow,lunw' 603 — ROOF BATTENS
01 ails exempt under Sea. .B&1'C for this season
/0604 — OOF 7N—PROGRESS
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby anlose adder proal,of ke,my aid ale following declamtinn.
I have and will mmain a Cenilicmto e of Consent wlf-inarfc far Worker's
lmpenmion, as provided fm by Section 370 if the Labor Code, far the
rerinnnanee of the work or which this Innnit is issued. k 1
Lase and will derision Worker's L'ontpensunion Insurance,as requited by Section
3 �K /
)of the Labor Code,for the performance of the work for which this permit is
J.M�Worker's I -inion Insurance ca a and Policy number arc: '-
M1 '4 araC 10—Policy No,
sg r23$_ L
A 11051 ION OP ban"
PROM O KERS'
CONIPUNSA'I ION INSURANCE
(This section need not be completed if the permit is for one hundred dollars
(51110)or leaf
I ocardy has in he f u it a.mak rit if he IM1 pe 1 . d,I
sM1 JI imply
t ( t t m W kcriso
N I fl ak gth n dE it Y should
k C pe t p n fth Lbt C d y dst
Osuchlrovivituo,or the Wrist shall he drainsW revoked.
yCONSTRUC ION LENDING AGENCY
7 1 beech,afeml that there is a conswerion lending agency for the perfomonec
of the work for which this permit is i,sucal(sec.3197.Civ.C.) .
0. Q !soda's Name
.7 Z Lender's Address
V 0 1 artily thus 1 Lace read this upplualion and stmt that the above iofts..n is
Gra F„ crime(.I agree In saintly with all city and county ordinances and.state laws alining
0 V to building construction.and herehy authorise representatives oflhi,coym camels
f the aMvo-mcntioned p openy for recreation ponoses.
CL. (We)ugae so rave,indemnify and keep harmless the City as Cupcnina again,
fin Nobilities.jargmcul,costs and espmtws which rimy in any way:...rise agniml send
U Z Chy In cansryucnce of live granting of this pemal.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT •]SSUedb Date
SOURCE REGULATIONS. y'
Signature of Applicant/Contractor Date Re-roYIN
IIAZARDOUS NIA ERIALS DISCLOSURE
Will me applicunl m boom budding occd and moles nr bailie bwunlaus alumnus Type c
as deeded by me Col<nioo Mddicipal Costs,Chapter 9.12,arta me Hcaltn and safety
Code,Sermon 25532(0)!
OYc, '0 No All roofs shall be inspected prior to any roofing material being installed.
Wi Il tire applit:rdtortrade blmdr,oaulall use equipmcdtordevices wfacts If a roof is installed without first obtaining an inspection, t agree to remove
mil Iw;ad atis air conoaninu it,rix defined by the nay Area Air Quality Management
District? all new ma erials for insp etion. Applicant understands and will comply with
7O Yes 0No all non- t source reg atU
I have read she teourJom drmend,requlrcments under Chade,695 of the --C
alilimtiuIlcnhh&Sufmy Cole,Bemoans 255(15,25533:mJ 25534.11 deraoudthan V.
it the buildingdna,not I rally haver,meant.(ho II ismya,larodulhy u.notify Cho ldv
tecuponl of the mluirentenn which door heroics prior to i„um¢r r.1 a Cenili'an,o1'
Oce. Y' '— 'gnatnre of Applicant Date
or amon,ed is m All roof coverings to be Class "6" or better
OFFICE