04040111 ;�(U,DJNG
TY orCUPEIV11NoBUILDING DIVISION PERMIT' . CONI=RACT012I N1±ORMATION ,i
ADDRESS' PERMIT"004040111
711 DRAKE DR
ER'S NAME: PERMIT ISSUE DAIS
DEREK CHEN 2 4
E. SANITARY NO. CONTROL NO.
ARCIWFECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LIC �7
o p affirm
that
I a CONTRACTOR DECLARATION
e I hereby affirm that 1 am IianccJ under pmvislonx of Chapter 9(commencing Job Description
,« wib SadonTIXk)of ne
Division 3or me Brns, le
and profession.Co .and my linen.is
_gym in mu teres and sere" ADD 146 SQ. FT/KITCHEN REMODEL
rM K. License Class Lih#
Lf,O Date Contractor
LoL F'4 ARCHITECTS DECLARATION
G d
y-a I understand my plan.%shall be used as public records
JU
ioN Liccnud Pmfcssinnal
i S
OWNER-BUILDER DECLARATION
a 1 hereby.Item that 1 am eacmlY from the Contractor's s License Law forthe
nty
p O followwhich re uiresreason.(Seaton)I13 L5,Business and improve,
cs,de i demolish,
h,Code:Any city rr muoy
m which requires a permit m construct,alter,improve,demolish,nr repair any ametum
thathesl Sensed pursuant
the provisions
ro applicant for Contractors
ontrator mRlpaa Law(mtemcnl
Xr-s (commencing
withSeauantntbepmvivision the of
usines'andPtielaw(chapmr9 Sq. Ft. Floor Area Valuation
y F� Oom a is CXr with um fond and Ji basis for
of the Business ptiontfAn,ns lato)of
Q�� ma he is cacmpt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a parmhsubjects the applicant o a civil penalty of 3 16d121lR&er0 0 Occupancy Type
not more than 0vc hundmd dollars(SSW).
P Y YP
❑1,as owner of the propcny,or my employees with wages as their .to eo u'ruslion,
will Jo the work,and the strunute is not intended or offered for sale(Sec.7W.Business
and Pmmssions Cooke mor
e:The Com � 's Lice a Law does not apply to an owner or Required Inspections
property who builds or improves therein,and wha docs such work himself or though his
n employs,provided that such impo old Wit we not intended moffered for sale owner
h deer ,the have
the
burden
of pment roving at he did
of year of improve on,for thepurpose
of
ase.).(will have the burd<n of proving Nat be tliJ mol build or improve for pope. of
vie.).
1.as owner of one property,am exclusively contracting with licensed conhacmrs to
On met the project(Sec.o an Business and rtowho Ws ds or hThews the
oe'e rad
whocomctawdoes tsfors such
Prapply roan With
of property wchrooddarrimptorth therern.acand,
Liven.Lads for sueM1 Projects with a eomranor(s)licensed pursuant to the Conuactrr's j
Liccnu law.
❑1 am carte fedee See n D &PC for this
'1�\ WOORKER'S COMPENSATION DECLARATIOrel
I hercbyittoter under ¢ f tleclaratiom: ��
..fly perjury imerf the fallowing
1 have and will maintain a Ceni fmm
fiesta of foent to self-insure for Worker i Compc
sation,az provided for by Section 3700 of the labor Code,for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3908 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cubic, Policy No, _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the Permit is for one hundred dollars(Slap
or lass.)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner as as to become subject to the WorkersCompensation
Laws of Cid front..Date
Applicant
NOTICE TO APPLICANT:If,after making this Comficare of Escmption,you should
become subject to the Worker a Compensation provisions of the Labor Code,you must
z forthwith comply with such provisions or Nis Permit shall be deemed revoked.
ZO CONSTRUCT]ON LEN DING AGENCY
I" I hereby afford Nat there is a construction lending agency l or the performance of
Qi the work fur which this Permit is issued(Sec.3097,Civ.C.)
!S7 Q Lhh&es Name
0. Lenders Address
�z
V O 1 certify that 1 have read this application and sort Nat the above information is
e, P correct.1 agree to comply with all city and county ordinances and slam laws relating to
0U building construction,and hereby authorim opmaenotives of this city to enter upon the
r G a hovementioned property for inspection Purpoxs.
(We)a rte to save,indemnify and keep harmless the City of Cuycninr against
F' N liabilities,ju u,costs and capcnsc.which may in any way income against said City
U z in uthon, c t Framing if this permit.
APPLI ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR L ION A/_ `,aid
Re-roofs
e
HAZARDOUS
AZAR pbaaroe
HAZARDOU S MATERIALS DISCLOSURE Type of Roof
Will the a C�ram m fount building occupant r 9.1 m handle Health and
az defined by the Cupcninn Municipal CoJc.Chapter 9.13,and the Health and Safny
Calc,Section 25532(%)? All roofs shall be�Nr inspected prior to an roofing material being installed.❑Yea
Will the applicant or Ionic buildin•occupant ore e If a roof is installed without first obtaining an inspection,I agree to remove
PP g P equipment or devices which g
nit hamrdnus air contaminants n defined by the Day Arca Air Quality Management all new materials for inspection.
"ale"
❑Yea XNu
I have mad the ava�tlnusmacrialsmquiremenuunder Chapmr695of Ne Califrr
Ma health&Swa{ef}Co c 'cctimv255)5,25533 and 25534.1 mosersmnd that irthe building
does not cuff t l g t.Nat it is my responsibility m notify no occupant of the
requi Ire ' sen Prior wissuance oracenmcaeofaepolre. Signature of Applicant Dale
lQ fl
true authmived agent `D All roof coverings to be Class "B" or better