03030009 CITY OF CUPERT[NO 'fA `
BUILDING DIVISION PERMIT CONT C%T,OR INF:ORsMATION ry:BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT LSSUEDATB
WA
NE: SANITARY NO. CONTROL NO.
ARCHITEC IENOINEER: BUILDING PERMITINFO ME
BD O PLUMB 'CH
O !�
3oG LICENSED CONTRACTOR'S DECLARATION IOb Description
1 hureby grim Out 1 am licensed under provisions of Chapter 9(commencing
with Section 70(10)of Division l ofthe Business anal Profession Code.and my liCo=Isfinfiflifo
LIC,,moci andcr?tttl' q BG 9 NEW AWNING
Lkeuo n s Let. Lk.N
Doss Comru ✓ n 1
ARCHnECCSDECIATATION CONTRACTOR: .REAL. SIGNS
3 ®'■mak`, p p`�^y
i? 1 undersmnd my Plans shall u rec
l used public ord. ' r ■_AL`r.
o EEE��i777
;0th Licensed Professional
OWNER-BUILDER DECLARATION
ai<x I hereby affirm that 1 am exempt from the Contssctors License Law for the OCT 1 -!�Z0
00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
$jyi which requires a Feng m consumer,alar.Improve,demolish,m mpJr any annum
_ prior to its Issuance,also Acquires the applicant for uch PCrmlr to Ilk a signed statement
'ay'<
that he is licensed punmAnuo the provisions of the Contractor'Wcensc Law(Chapter 9 Sq.Ft. Floor Area bulltmeon
t� (commencing with Sutton 7000)of Division 3 of NC Burinwand Professions Code)at '
B that he Is exempt 0oaefran and Ne basis for 0rc alleged cmmpdon.Any violation of 8800
Section 7031.5 by any applicant for apermisubjects the applicant to a civil penalty of APN Number Occupancy e
not mare Nen It.hundred doled(SSW). P y Ty Typ
❑1,uawner of Rue property,or my employes with wages as thebsele Compensation, 32634064 . 00
will do the work,and Ne annum is notintended oroQered ronalc(Sec.7011,Businw Required Inspections
and Prom Professions Code:The Contractors Lt..Lew does not apply an owner or - 1 O 1 — FOUNDATION p
propeny who bu llda ar impnow a Neeson,and who doeuuch wmk himself or through his -
meemployees.provided Oat seek Improvements amnot lmmndedoroReredforssk.If. 103 — 'iIFER
howewo Ne building or improvement is veld within ane veer of completion.Ne owoen
Wilder will have rix burden or proving Our k did not Wild or improve for purpose of 104 — REBAR
ask')' 105 — ANCHOR BOLTS
0 1,as owner of the property,am exclusively contracting with liconud contractors to -
coutructtbepmject(Sec.7Dna,Butiness and Profusions Cade:)The Contractors Lt. 304 — ROUGH ELECTRICAL
come Law does not apply to an mna of property who Wilds or lmpmm thereon.and, 'SOS FINAL ELECTRICAL •
who Contracts roc such projects with a eonuscNrp)licensed pursuant to the Contracts
License Low. 514 FINAL PUBLIC WORKS
O l am taemptundn See, .B At P C for this reason
weer Dau
WORKERS COMPENSATION DECLARATION
I hereby a111m under Foully of Perjury one of the following declanrionsi
I harc end will malnuina CenlEceu of Comenuossl6lneuro for Workers ComPen•
asamn,u provided for by Section 3700 of The labor Code,for the performance of the
work for which this permit is issued.
❑1 haw and will maintain Workers Compensation Insurance,so,required by Section
3700 of the Tabor Code.for the penormanec of tie work for which this permit is ussued,
My Workers Compensation luvnnce Carier and Policy number art:
Cartier. POLICY No.; -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thus&nim need net he completed time remit is foram hundred dollars(SIM)
mks)_ __•__ _ . _� _ __..�___ _. .—_,. _____ _ __ ___. ._.___ _ _ _
1 eerily that in the Performance of the work for which this pormit is Wood.I shall not —
employ any permn in any mennerw as m become subject to Ne Worleca'Compensation
Laws of Califomia.Dam _
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificem or EXCMPIIDn,you should -
become subject to the Worker's Comronnsomn provisions of the lobo Cade,you mum - -
.,O forthwith Comply with such Provisions of 01,remit Nall be deemed mvnkcd.
Z2
CONSTRUCTION LENDING AGENCY
hemby&flim that tem is a comimcdon lending agency for the perrormante of
G'
the work for which this permit Is Issued(Sec.3097.Civ.Cd
W� Q Lender's Name -
Z Lenders Address
U 0 1 ttnify that 1 how mad this application and auto Net the show Information is -
U.(•' correct.1 agree to comply with all city and county on iusnces end amu laws misting N '
0 C.I building emanction,and hemby authatlw aprescowiws of this city to CAW uFnn the
lt1 aMrc-mentioned property far inspection purposes.agme m use,indemnify sed keep harmlw the City or cupenino against
.a
CA liabilWes,judgmbngcosts and expenses which may In any way aceme against said City
L) 2 In consequence,or Ne graming of this permit
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date�/PA
.
SOU =�.
% �N/o_z Re-roofs
Si arApplio11me.
Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant am orhandle haxamb us material
u dented by the Cupenino Municipal Code.Chapmr 9.13,and the Health and Safety
A Section 25532(a)?OYea ONO All roofs shall be inspected prior to any roofing material being installed.
W01 the applicant or fuum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It baurdous air cenuminants as defined by the Bay Area Air Quality Mengement all new materials for inspection.
is
0You ON.
I have reed the haumdms materials requirements undcrChapmr 6.95 or the Califor.
nla Hold,&Safety Code,Sections 25505.25533 and 25534,1 undemmJ Out lithe building
does not currently law a Truant that 11 us my uapousihllity te notify ties occupant of Ne
ulrem uwid mu I ata rmiuuanaafaCerIEEia or upucy. Signature of Applicant Date
s�u1 �' All roof coverings to be Class "B"or better
mer m euthm.d a em v De¢