01080008 (2) CITY OF CUPEICONTRACTOR INFORMATION:
BUILDING DIVISSIONON PERMIT
BUILDING ADDRESS: PERMIT NO.
22140 WALLACE DR 01080008
MVICH ROBERT B AND RITA S APP{,ICJSt1ofI�31J ff,
PHONE: SAANII�TAARtYJ NlO/. ulJ CONTROL NO.
QQ 0 ARCHITECT/ENGINEER! BUILDING PERMIT INTO
HBLDG ELECT PLUMB MECH
a i W 1=J L--.l
Gad
ozH= LICENSED CONTRACTOR'S DECLARATION ����bb pp
-a ction701I hereby ofDhmion3I am ofenxJundesandPiofsof sinhapter sCode. (commencing ELECTRIC SUBPANEL/5������E
Ern 1_ with fall foneandef Division 3ofthe Business and Professions Code.and my license
¢m ac� is in full flim,and,Bert.
rc te 6 0 Licenx Class Lic.p
ou Dam Contmeow
H u O G ARCH(TECT'S DECLARATION
g 1 mile raanJ my plans shall be used ns public records
0 Licensed Professional p
OWNER-BUILDER DECLARATION
- 1 rcuoo ,Sc,l Inst 1 am exempt from the Contractor C's License law for my
S'�.< lallnwinp mascot.(Serum 7011.5.Business and 1'rvfesnanz Cale:Any city ter county $500
i=❑ which requima a wont to conslma.alter,intprme,demolish,or repair an)structure
ou 3""pmart am ace.a1wreq 'rridi pplicatf hpero Ito,fl geed xtaam,nt - - - - --- -
mmnTl nxdpars_UaNtotliepa rtn c wrorsL, .eU '(enapmr9 ,,,.,w,�3210$OFJ�CB@a- Valuation
(co bad - gwim Sech 700L fDvts 3 fth Bines. nJProfession,Gude) yt tt A., y fl E(.:,.f ,f�'v
tr ohm c,,
exentpi therefrom and the basis for the alleged alemp0un.Any violation I
of nottmom than5rm any
ed delta,,(Slicant for a 5W).n subjects the applicant acivil penalty 304APN IQQUUH ELECTRI AL" OP Y ccu ane TYP
e
131,as owner of the Proper,or my employes with wages as their sole compensation. 501 — FINAL ELECTRI AL ENERGY _
will 1.
ne the wProf Professions
areata,is not intended or enertLaw for tale apply to an 505 — FINAL EIIFkW lJections'
will d s the Professions Code:The is nttainten License Law dors not apply to an "
a
r of pmpcny Who builds or improves thereon,and who docs such work himself
Lrt through his own employees.provided that such improvements amwithin
not intended or .--
'offered forsake.If.howcv,r,the Wildin ' - Tis salt-within one�ear of
ge imof pro y
impletion,the owner-huildcr will have the harden L[proving that hodid not milder 1
improve for puryL<c of pule.). '
. . .._...a exclusively
._". . .. ._-
X.as owner ai m� rtcontractors . . ..... . . . .. .. .. FINALEC ...... , - .I :
prop, y,amc Business
Conr rs
Li swot the project(Sec. to ovocass aid Professions Codon Th,Co therecto
License Law does not apply.t an owner of property who Wilds or improves m1.the
_ -and who',License
for auch.pr°ja¢with a eonwanels)lia¢sW Ponstan!to the
Ganwpara Lipenx law. SER-13 3 2001
_-
El am pt und
eer Sec. B&PPC for This sawn
Date '
V WORKER'SCOMPENSAI[ONDECLARATION BUILDING
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cer ificae of Consent to self-roma for Worker's
Compenwion, a provided for by Section 37W of the Labor CWc, for the
Performance of the work for which this permit is issued.
❑I have and will maintain Worker's Contpensat ion Instance,m required by Section
30W of the LaWr Code,for the performance of the work for which this permit is
Issued.My War cis Cnmpensatiun Irtwmnce garde,eta P°Ilcy numbeq arc'.
.. r ... .- ._ _. u.:.. ... _. .� .. _ ..-... -
Cane: yPol yNt.. r 144 t ek `... J.1 `'`;
t CERTIFICATION OF EXEMPTION FROM WORKERS', - - -
t� COMPENSATION INSURANCE g - .. _ .•..._
(This xeninn need not be completed if the pewit is for one hundred dollar
(SIM)to less.)
it I seen ly that i t tM1 pe Pormancc t f the work for which this per nit s issued,1 t .^�
.hall not employ any Penson In any manner w as to become subject to The Workers'
Compensation Luw.iof Callmmia.Dam '
Applicant
NOTICE TO APPLICANT:.H.afar making this Certifcam of Exemption,youphould
beom
ce subject bath,Workerm
Workers Copcnsaw provisions of the Labor Code,you most
O forthwith comply with such provisions or this permit shall b,deemed awaked. l
_. .. .. _ . _. - . _ .
F•7 u ' -• CONSTRUCTION LENDING AGENCY .. .
1 hereby tf rte th t the a const t Sag agency fonhe performance
E-7
ssap
y 0 Lither'sNmrwh<h th eat d(Sec 309).Civ.C.)
-lender's Nnme
D Z Lender's Address
V I cenify that l ha s,readthi<application and slam that he above infnrmutlon is
Lm F„ cotrect.I.,me to comply.with all city and county ordimncu and state Iaws reining
. Cyr, to building construction.and hereby riamona reprexaalves omnis city to enter upon
>, Ld the above-mentioned property for inspection purposes.
F y e,judgme to save,and n persesk hi h may in anyway
srac u c rgn in gt said
U�Z Coyrr' j dy tc,,fine d Por mi h h Y many y e Foinnt said
CitySTAN t NDWILpermit.
'SPP C TC 1 RSTAN SAND WIL COhIPLY WITH ALL'NON POINT IspLled by: Date
Yg9 . D'fi i p l u 1 1 Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will theeCr,amor rams Wilding occupant store in Handle Health
S.I.1y ._ Type Of Roof•—.- •. . . .._ . .••..
as defined by the Cup,nino Municipal Carle.Chapter 9.12,and the Hohh and Safety _ \ of � •
Code:Section 25532( " •' ::;Y, .
❑ver ' 1- -�No':"t ---All roofs.sitall be.inspected.prior to any.roofing material,being installed......_
IVillmhe phcartor fma,,build in,o.a,inta,c c,poctit or device.which! If a roof is installed without first obtaining an inspectiori;'I,agree to remove
antit hnaNLa<air crmtarorants as de9ned by the Bay Area Air QuuOty Monagemem
District. all new materials for inspection. Applicant Understands and will comply with
-' ❑rep - - ' • - - all non point source regulations. s
1 have read the hai udons macrials requifemetna under Chapter 6.95 of the
California Health&Safety Code.Sections 25505.25533 and 255}1.l understand that
JI�t� bng docs not cuncnJy ha4e a¢nam,that it is my«spunsibility to notify the
N on,ir mems w ich Trust be ntbt prior m i,,uancc of a Ceriliwm of
Signature of Applicant Date
Owner or nation .'emDam All roof coverings to be Class "B" or better
'OFFICE