01110111 OF
CI BU7 DAC DIIVIISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21458 METEOR DR STONERIDGE ROOFING '01110111
` OWNER'S NAME: .. APPLICATION SUB DATE
ANNE PLUMER 1643 SHORTRIDGE AV 11/27/2001
F- (408) 729-5101
aHONE: SANITARY NO. CONTROL NO.
O ARCHITECDEN'GINEER: BUILDING PERMIT INFO
U ELECT PLUMB MECH
u I ,
G
Sh= LICENSED CONTRACTOR'S DECLARATION
=e I 'I hereby arum mm l am ecensee ander promasmns or chapter 9leommenemg Job Description
701-5. with. moo) fo 0 3ofth eine and P fes.' cos npmylicense REROOF
as 5,d
s ul 1 rFC
io6.f� n2o t7t . . _ , u<.x ..
1 3.LL l-ihat ARCHITEcrs DECLARATION
''=0 l 1 to demond my plans shall l e used as public rewrds
i p O Llcemed Pmfenional
^ OWNER-BUILDER DECLARATION OWNER-BUILDER DECLARATION
=':r 1 hereby affirm that I am exempt from the Comecmr's License Law for the
following rcasan.(Section 9031.5,Business and Professions Cede:Any eiry of county $8600
Y F po which requires pc n t o Icor,imp demolish.h, p y mvcte
3 ac pnart u u arms Iso req the pplTam'f M1perni uo fl gned"ate
__------
"w"hale
_ _
Cosi hq 3ltt eedprspn"glhe pro . ns of theC tCIO"
i sL la (Chaga9 ,/ •.r,, .;a3gr^;y'r, ®pep..q,x�,r p yF.,. -- Valuation
(commncmg with Section 91110) fEr "Ont fth B5-uses,, 'to
scud ) f_,t, .�. t. LU 44 6�-;17 yW�4S..RTi;.•.
err that fie is exempt therefrom and the Ws6 for the alleged orseen on.Any violaion
in Section]031.5 by any applicant-for a permit subjects the appticenno a civil penalty
sof not more roan rive hundred donors HIM), 3 0 6PIY NPORE , i..'' "i Occupancy Type
01.as owner ofthe pm,si or my employees with wages is their sole compensation. - INSITTATION
will do the work:and the structure in nm intended or nBen:J for.sale(Sec,7044,
Bushmos'and Pmferslons Code:The Con niClar's License law doe,not apply to an 601 - ROOF TEAlPluiDgYnspeelioils I „fir,.• '
r of property Who builds or improves thereon,and who does such work himself
err through his own employees..pros ided Nat such ire is are not intended of 602 - ROOF PLYWOOD NAIL
offeredfrr"izlc.If.howcvcr.the Wilding or improvement is sola within one .._. f.
g p a° 603 - ROOF BATTENS
completion,the purpose
of ale.).win have the burden of moving that he did nm build or
improve rim parpo.e or,ale.). 604 - ROOF IN-PROGRESS
_13 1.as___-cof . ii
eomrnim tianed eonvxmu m ,t p1 In,
. t r.'.
-, construct the project(sec.91Business and professions Cade:)The Connector's
License Lowdocs not app1Y I.anowner.fpmpnY
who builds or improve,thereon,
C
-and who contracts.for.such projectwith a cou'rvemr(s)licensed pursuant tome. _._ _. . _. ........ . .. . _ ._. _ _.... _—... ...__.._.._
Contractor's License law; 4 _I� ___
❑1a exempt under See. A" -:B.&P C for this reason
- ; O;,mo `'.L,:. .' ".." , Date . DEC,0,5 ,2001
fPp,3:ygJ!rIy WORKER'S COMPENSATION DECLARATION � '
' U '^Pherdby aRmi under penalty of perjury otic ofthe followingddlmations:
�� ❑ 1 have and will'maintain'a Certificate of Consent to self-insure for Worker's BUILDING
av IComp,mamion, as provided for by Section 370 of the Labor Cade, for the
performance mf the work for which this permit is issued..
❑I have antl will maintain Worker's Compensation Insurance,a required by Section
37W of the Labor Code,for the performance of the work for which this permit is
-' masted MyW kers Compc '. to I .umnc Frier end Policy numbcrarc. _
• � rte P°lic N is
. ', C2RT (CATION OF EXEMPTION('ROM WORKERS'i "
.. ,_..:. . -COMPENSATION INSURANCE,,•._. .._.. _._ .._ ________...._ ._.__....__ _._.�___._.-_.__._-_.._..__.___ —___.._._ _ __._. __ ..-___.
•,q.? ...
m 1c sccuon otic]not he annplemtl if the permit is for one hundred dollars
(SI00)or less.)
I c rf fy that in Person in any mcc of th k for become
tri:Permit the
xuo4 1
shell not employ any penon n any mama m is to become subfen w me Workers' '
Corlicantfortravart laws of California.Dam
NOTICE TO APPLICANT:IL after making'his Certificate of Exemption,you should
beenime subjecuo the Worker's Compensaion provisions of ine labor C«Ie,you 70th
Q 0 fnnhwith comply wish such provisions or this patent shall be deemed revoked.
... . .. ...- -- ' - _ _.- . .._. ... ...
yI .*'CONSTRUCTION LENDING AGENCY ' I -
1 herchy affmm th t the a< nsaua ding ugenfy friih per(sirmabce '
r of the work for which this perms i, .sued(Sec;3097;Cie C.)
Qlender:Nmea .... ... _ _. .. .... .... ._.. - - - .- -. .. _..
7-Z Lcnacr's Address
U 01 unify that 1 have read this application and s'a'e that the above information is
{an F., cadect.-I agree to comply with all,city.and county,ordinances and state laws,nlahng ,
OU to building ronstmDtion;and hereby aum'orize represcnmtives of this city m ether upon
the above-mentioned property for inspection purposes., ,
.Fi F• jime)agree to save;indemnify and keep lemankssthe City of Cipcnino against
y liabilities,judgments,.,is and expcmes which may in any way accrue oguiml said
U sZ City in comcquence of the granting of this permit. /, �� _11I
A "(CANT UNDERSTANDS AND WILT.COMPLY WITH ALL NONAOINT ' Issued toy: Date ``VV
URC y'
�.-.m�� fiyntrleL UJ�'7obL
'gosh...of wroodcommorr'. . Date Re-roofs
HAZ RDOUS'MATERIALS DISCLOSURE
WII'lie-pplicanto f niumbrilding occupint storeorhandl hazardousrrwenal Type of Roof - - - — - - .......
asdefi WbythCupcn oMunicipal Cade CT p' 912 cadre Health mad safety .. s.i t1^„ t " -
Coda SeaOon 255321)^ fie �' - 1 h� 1' ! ' •I '1` .�,s ' '
ave.' !'ON i. , e 6` All roofs shall be inspected prior to any_roofing material being installed.-. . .
I ,.I Will the applicant or future buildingoccupant use or devices which
oc pan equipment If a roof is installed without firs[obtaining an inspection, [agree to remove
emit M1aznrdobs air con'aminanta as defined by the Pay Arco Air Qdaliry Management
oisdi<e all new materials for inspection._Applicant understands and will comply with
❑Ye oNo ' ,, I, all non-point source regulations..;
1'ha e r W me Safety
Code.memns 2 505 ata under Chapter 695 of the
California Health&Sufny Code.Sections 35505.255]3 and 25534.I understand that •L' -
ifthe Wilding dons notcurendy have rtenam,tout it is'myrespensihilhy to easy th � G 'r�nQ/_/q� 11 q7 Zoo/.-
occupant of the requirements which must he met prior to issuance of a Certificam of gg�C 7 ���YYY TMS
opapey.. 2PI - Qqp Signature of Applicant Dat
_
eIs
rte oozed erg<m � Dine All roof coverings to be Class "B"or better
•.
OFFICE