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BUILDING DIVISION PERMIT
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LICENSED CONTRACTOR'S DECLARATION
1 hereby aRrm dtu 1 am licaved ursda previsions of Chapter 9 f.rociing
with ScWim700D)ofDu,W.. 3 ofthe Business and Profasiens ,yW my license is
in full force and eRat. 0 Y
IJanx Cla lac. g
CH LTS DECLARATION
1 on nd y I used u public minds Rx
Braved Pmfealorol
OWNER -111 -11 -DER DECLARATION
I hereby affirm the) am eacmpt from Ne Convector. License law for Ne
following reason. (Section 7031.5. Business and Professions Code: My city m county
which requires a permit to construct, alter, improve. demolish, or repair any structure
Prior to its issuance• alw requires the applicant forsah permit to files sigrld mitamem
that he is licensed punumt to Ne provisions of the Contractors License taw (Chapter 9
(commencing with Nation 70(10) of Division 3 of the Busimas and! Pref nsiotu Cade) on
that he is aempt therefrom and the bits for Ne alleged esemplim. Any Ankhon of
Saidon 70313 by any epplicam fur • permit subjects the -,It ' to a civil penelry of
I mom than ria hundred dull. (5511111.
1, asowns of the progeny m mY emplryeca with wages u their role compcnetion.
willdo Nework, and Ne structureisnorint ndedmoffemdfmak(Ser.7W,Business
and Profeaiou Code: The Contractors Lianx law does non apply to an owner of
propeny who builds or improves thereon, and who dose such wok himself in through
his own employee, provided does such impmvemenv see not intended or offered for
sale. If, however, the building or improvennenr is sold within one ynrof completion, the
mr-builder, will have the buNcn of proving that he did not build or improve for pm -
pose of ale.).
1, a owner of the mpert , am emimlvcly convecting with licensed cominmon m
construct she project (Sm. 7W. Business and Profeafiou Code:) The Comecmrs V -
cents law does not apply In an owner of,m,mOr who builds Or irn,mva tharso . and
whocontrwu for such mi.. with • mntrecta(s) licensed pursuant to the Contractors
License law.
❑ lamearcromda Sec. .B&PCfmdiisrtawn
A'amoDa.
WORKER'S COMPENSATION DEMRATION
1 hereby affirm on4r pen0y of perjury one of the fallowing dedaretion:
i] I have and will maintin a Ccnificate ofConntl m self -insure for Wohera Compen-
udon, ns provided for by Section 37W of the Leber Coda, for the performance M the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compenation Insurance, as required by Section
37M of Ute Labor Code, for the pcRormanee of the, work for which this permit is issued.
My Workers o t'r�ae caniermd Policy nufR�rkf+'s/'1 :Z/
Cama: ,J Policy No.: /TI a�� i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This wclion need not Wcompleted ifthe prmrtitis finene hundred dollen (5100)
or leu.)
I certify lhat in the perfoturmceoftbe work for which this permit is issuers I"I
tm1 employ any promo in my meaner w as to become subject to the Woken' Comp-
action Laws of Celifomia. Dare
Applicant
NOTICE TO APPLICANT. If, after making this Cmificare of Exemption, You should
become subject m the Workers Compenation previsions of the Labor Code, you must
forthwith comply with such provisions or this pemsit dWl W sfamed revoked.
CONSTRUCTION LENDING AGENCY
QIhrrebY affirm don them i ... mumaomm lending agency for the Perfumwce of
Z
`the work for which this permit is issued (Sec. 3097. Civ, C.)
Lenders Name
a > i.WreaAdLea
R] I certify dial 1 have read this application and sine that the above information is
0. ^� correct. I .gra to comply with all city and county odinenus and state laws misting to
Z timidin,mumituctim, nd hereby autharire a,mumutivaofthis city to anti upon dte
U O above-mentiund property for inspection purposes
(We) egrtc m ave. indemnify and keep harmless the City of Cupcninc against
U lie' 'ndgmentf, su and apensex which may in my way creme against said City
y W t onsequ a Ne 8 murtg of this pemdl.
y 9'LICA Ik' BiN. fANDBAND WILLCOMI'LY WITHALI. NON-IY)INT
V URCEI I1 ATI( S.
rex of Apph .ndQontaaer 3
HAZARDOUS MATERIALS DISCLOSU
Will dre a C. ml or future Wilding acup.... tart a handle hHeadous mmerii
u defined by the 32(s)? no Municipal Code, Chapter 9.12, end flue Health and Sarcly
Cade, Nation 25512(«)1
❑Yes No
Will the applicmt a future Wilding acupant use equipment or devices which
mil heramoua rev contamitanu as Bad by the Be, Arca AU Quality Managemem
-1n tl
C] Yes No
1 have mad the f materia a mprirtmena under Chaps 6.95 ofthe Cali
fomes Health & Safety Code, ectiens 25505, 25533 and 25534.1 understand that if the
Wil M e e tenant this it is my rnponibiliry ramythe occupant
of she aqui. u hi t mel'ria to isamnce of a C fXy'u�+heY.
Owner or Nona t Dare
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Job Description
362
Mo3ooF2COL,
CONTROLS
MAR 0 3 2000 U1
t
l•s l
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is Installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant • Date
OFFICE
All roof coverings to be Class "B" or better