02020072 (2) CITY DN
PERTONO
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: APPLICATION SUR DATE
AGRESTI ASSOCIATES 1250 BIRCHWOOD DR 02/21/2002
PHONE: SANITARY NO. CONTROL NO.
S (408) 734-4282
COO ARCHITECTMNGINEER: BUILDING PERMIT INFO
p, BLDG ELECT PLUMB MECH
y<6
c In= LICENSED CONTRACTOR'S DECLARATION Job Descri non
I h,reny arrrn,mat 1 am teen.<a ands prnvP I ar ewpde9lcammcneing P
=mFw with S«don7000)ofDivision 3oftheBut mr onsts"mr, We,andmyliceme TEMP POWER.
Y.esi is in full d Be, OS Q
z K 6 License C n s
Z 0 i, ate 1 e n Comra<•�gf
+� In ARCHITECT'S DECLARATION
}g I understand my plans shall he used as public records
i 6 cm p O Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm,hat I am exempt liom the Cm,m,o is License Law for the
m
C?a following mason(Section 9031.5.Business and Professions Codr.Any city orcounty
E D which requires a pemnt to mn%mact,alter,improve,demolish,or repair my awmum $1000
Imjr —Q _.pronot c l0 4 th ppl'ani for such pennu to file a signed statement.
n3— tha,heglcenledp,puanr,oMcpm oftkCon,mnorsLicens Uw(Chapier9 r,. T- yyv Sq..Ft: BloorrA;ea,, 3 p., Valuation
tc;rn cng, hS a AIgO)pfD n3ofthe Bustnessand PrP@ssons Code) .�t�� Ll- S ix' r._t .:�.�r erg;
trm.n be x,xen;plm<mr�anand the bat.far the mRja,jcx&,1ptn,o.Any v.Intan 3L6240'GO 00
of Section 703 15 by any applicant for a permi,sabjcc,,the applicant to a civil penalty
car norm.<thanfi.chundreddollars($50B). APN Number .. .., . Occupancy Type
01.as owner of me rr.orm laces wan wages their:ale compensation, 103 - UFER
grope Y m I, Y r offered
perish
Bu Ptlo the work:and"Me swnure'C .Tactor',Li or offered for sale apply to an4. --- —'-'— - -'-- - --- -'Business iand rrofa ofWhom builds
Code:The Contmmor's.and w Law
docs not apply to an eq ire nspections'N`
owner of progeny Who builds m improves at such improvements and Jolts maM1 work nded lf
or
or Mrough his own employees,provided Ma,such irmatiart not intended or _ _offered for sale:If;M1oweve{Ihe buildin— — em is sold within atilt jetir of
completion,for Pu poseownerof ale.).willhave Nr,burden of proving that he Jitl not build or
'
t
improve Purpose of sale.).
p p. . _ ._._..... __. _. . .... ..___...._ .. _.____.—___._....._F �.^.r _ _ _ __ ____
_ _ ❑1;as nwnegof IM1e progeny,a xclusively enntraceng with licen,ed carmucmn m �� �'`D t:i' u "L. ••) ,.ca
construct the project(Sec.)UIQ Business and Professions Cod,:)The Conoacmr's f ,
License Law does no,apply to an owner of propeny who builds or improver thereon, Q
" -and who cn . mmor(
-contracts.for such pmjesa.conts).licensed pursuant to.the
Ganma<tar'a Li«nm lmw.. . -F-E'B 2 5'Z
Olem accept under Sec: ,_.B&P C fonhis mason
- _ own. BUILDING
_ WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pcnahy of perjury one of,he following declarations:
i ❑ 1 have end will maintain a'Cirrcate of Consentto self-insure for Workei s
Compensation, as provided-1'or by Section 37W of the Labor Code, far the
Performance of the work for which this permit is issued.
❑1 have and will'narmtdin Worker's Cumpeniation Insurance,as required by Section
37W of the heli,Code,rim the ye'rformance of the work for which this Permit pis
•- issued My Worker's Compensation Insbmnce Lamer and Policy number am:
.. . i •. ..,� . ............. .. .........
. cert STi➢7fa'+Ce;.�g�.vliPamyN iuL9af3/O/PCMB' p '�J> isIyItly :^.y'� ♦ �f ,.rlt. .
CERTIFICATION OF EXEMPTION FROM WORKERS'(- - {. i}�. 1 {�,xt S- AIT _ I�.\tick -1_
COMPEr r!NSATION INSURANCE c`"'-^^ -
Ths smuon need not he mmpineJ f tM permit is(m one hundred dollars ''' ' - 'I +it
($101))or lea.)
-Ir,rtfy that .. ., .. _. . _.._ _. ...
. . ... .. s .. .. ...
in the performance c the workfarbecome IN,ct t ..Workers'l ,. , ,r,',.,.
!hall not employ any pe if m any ma her so as m become xnb3em,o the Workers - 1
Campensmian Lucas of Celifomis:Dbtc
_.Applies.' _ _ xe ..—...___ ._____...__..__
should
NOTICE TO APPLICANT:I'sCompeasition prvisioso of Exemption.youuhimst,
become mbjectm the Worker's Compensation octan per uohall the Labor Code,you mu.a
Q �
forthwithco Ply tM1such p provisions permit shall bedeemed moked.
" CONSTRUCTION LENDING AGENCY
t•"' 1 M1 by f nn that the construction lending gen y f di pert nce + I -
ka7 �ofthe oWf 'hcn thxperm
(� F.enders Name -s_
_.z Lknddi Address•*.. sv .. .;'It•i.,.,:
i I i
C.71 e<nify Mat 1 have read this application and mate that the above information is
W'.[.. comb.1 agree,a romply,wiM all city and county ordinances and store laws relating
Wilding<onn,sinion.and here by ituthoriae ieprcsFntativEs of this city to enter upon
rte,) the .....carmacd progeny for inspection fathoms. ..
t.. iL (Wel hgr<c id save;indemnify end keep harmless the Cary of Ca'penino againn
to liabilities,judgment,cosh and expi which troy in any way wane against said
city in consequence of the granting of this permit.
'APPLICA'APNT UNDERSTANDS` ND WILL COMPLY WITH ALL'NON-POINT ISSUed by: Date
Dair Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ' "
W ll the applicant ar future Wilding occupanC tort or hard!e humd a mater al _. ..Type Of.Roof....
Cod r d by theCurrent p I M r Code,en pt 9 12 and the Health and Safety ,
de scton255326) .. `_Y''�
ore........ 'q [baa t 'J^,F,Y t; All roofs shall be ins acted prior fo any roofing rnatenal being installed._-
;.' p --
wumeappr t r� b la'her,r,appetaaeegavmeni��a,.a�wn<n - If a roof is ihstallil without first obtaining an inspection] agree to remove
emit hWAndows a, y e Bav Area Air Quality Management
cam am ss dc0ncd b th
uidn,r all new materials for inspection. Applicant understands and well comply with
oyes
t all non-poinfsouice'regulations.
1 h -d the h zard mat pals q crib and Chep` 695 of the
Cobfom,a HcaltM1&Saf ty Code,S¢t ons 25505 25533 end 255tq I undersmnd that
if the Wilding does not currently have a yuan:that it is mY«sionsilahty,o notify the . ...-
oicupan,of therequirem t which must be t p nto rssuance of C NGcam of
Signature of Applicant Dale
nwM a agent
All roof coverings to be Class"B" or better
.r �., OFFICE