09030077. x-
BUIL'nING DIVISION
18880
OWNER!S NAME' -
PEP -NUT
4081288_8
PERMIT NO.
PERMIT 1SSUEDATE
A
CONTROL NO.
S
BUILDING PERMIT INFO
ARCIIr ECT/ErIC'INEER: Job Description
y EXTNG CAPS
BUILT-UP RF W�60IL TPO
_R'S DECLARATION
SED CONTRALA o[ Chapter 9 (commencing OV ERLA
LICENd under provisions and my license is RE _ RF
I am licensed fcWuns Code.
I 0 0 I hereby affirm that, 5 3 S4
U � with Section ?000) of Vviaton 3 of the Bhtaincss and i' CLS A,
n < H in full force and If ( Lie. S
v� z License Class r
Conor acro
t: Date ARCIVM" u�S DECLAfz
RATION
t• � _ used as public records
r- < 1 understand my plans shall be
Da U fcssional ER DECLARATION w for the
tL t- Licensed Pro OWNER -BUILD or county
em t from the Contractors Li Anacity
n y alTtrm that I am ex p and Professions Code: ait any structure
lrebyn (Section 7031.5. Business demolish, or rep
'0 following reason-
rmit to construct- alter- improve' rmit to Glc a signed statement
(chap'
a� 9
e fA which tcqurres P° requires the applicant for such Pe tars Licen$e Law
a z Y prior to its issuance u ant1O the Provisions of the Conn o License Code) or
that he is licctts, P o(DivisioC (° �leged examPtio°. Any violation of
E m p with Sccuon 7000) the basis the applicant to a civil PenaY.lty of
t (commencing therefrom and rtnit subjects
.0 that he is exemptIPP licant for a pe
Section 7031. f ver any n edollars (�)• as their sole compensation,
not mora than a my employees with wages 7044. Business
1 as owner of aIle property' nse Law does not apply to an owner of
will doth° work and the structureis tors w� d or offered for sale ( If or through his
and Professions Code: The confide and who does such work himself Cor sale. If,
ves thereon, not intended or offered owner -
property who builds a imProimprovements are o[ completion. the
own employees, Provided that such imp ld or improve Cor purpose of
however, the building or tmproVe"renl to sold within o t Year
builder will have the burden of proving that he did not Mti
conuacting with licensed rn"�s Li-
rs to
0
am exclusively The Contract°
I. as Owner of the property and Professions Code) ver titereon, and
�nstntct the Project (Sec. 7044, Business property who builds or impro Contractors
cense LAWcontracts
ctxs
not apply 1O am °4th arcontiracor(s) licensed Pursuant to the
who conrracu far such Protects g & P C For this reason
License Law-
13
under Sec
13 1 am exemptDate
Owner W ORK11t'S COMPENSATION DECLARATION declarations:
one of the following
,q Floor Area
316 0 9 0 3 7• APL inspections
_ Required
1 hereby affirm under penalty of Per3ur7 esCompc"'
nt to self -insure Cor Wolke"In. of the
Section 3700 of the Labor Code' for the P°
j 1 have and will maintain a Certificate o
consent
satton• as provided for by d Scotian
work for which this Permit is issue as required by
Workers Compensation Insurance req rntit is issued -
and have and will maintain r{omnance of the Work for which this P°
for the performance and Policy number are: lr
3700 of the Labor Code
ration rance carrierD p
MY Workers compo Policy No.:
PnON FROM WORKERS'
Cartier CERT► F1OMPSATMION INSURANCE dollars ($ 100) (this section treed not be completed if the Permit is for one hundred
is
d I shall not
or less.)
W.... mmpensation
v at in the performance of the work for subject10ft
WO
coni(• that
person in any manner so as to born
I, any Pc You should
Laws Of California. Date tion. Y
Applicant this Certificate
o! ExemP ou must
APPLICANT: if, after making Provisions of the Labor Code, Y
NOTICE TO Worker's Compensation rmtt shall be deemed mvokcd*
become subjcctlt°W with such Provisions or this Pc
'z• forthwith comp Y rformance of
ON LENDING AGENCY
O CONSCRUCTi ctimn lending agency for the pc
' that there is a construction Civ. C.)
1 hereby which
this
Permit is issued (Sec. 3097
a r�-t
he murk for which this pe
L>a 0Lenders Name above information is
Lenders Address location and sure that the
p certify
this app and state laws relating to
,7 { drat I have read ordinances to enter upon the
LUL correct l agreeY to comply with all city and county
authorize reprcsentativrs of this city
building construction• and hereby no against
O U above-mentioned ProPcnY for inspection ion P"rP°seharm I the City of CsaidCity
H CS♦ liabilit( e) g agree n 10 save,os. osis rand t xP°"sesFdekGpicchh may in any way accrueagainst
of this permit WITIi ALL NON -POINT
in consequence Of the granung iD WILL COMPLY
ANDS Ad•I r+
Itcant/Con for ALSDLSCLOSURE material
,tgnature of App HAZARDOUS MATERI t store oc handle hazardous
al Code. Chapter 9.12, and the Heald' and Safety
Will the applicant or future building e, Chan
as defined by the Cupentno municipal
Code, S0Ye25532(a)?jNo
d by the Bay Area Air
it equipment or devices which
ling occupant use
defineQuality Manegcmcm
Will the applicant or future bu
.,it hazardous air contaminants as
District? No Calitor-
0 Yes ter. 6.95 of the
rials mquir°mcnts un -1 -dr f le tier building
I have mad the harardtws 2$534. I °"dcrsta"d occupant of the
25505.25533 and risibility Wnotify
nia health & Safety Code. L. that it is MY resW ancy.
does not c Y ha issuance oC a Certificalc of cup
any,
Date
zed agent
Date
I: sued by:
F.e-roofs
--ype of Roof installed.
prior to any roofing material being en to remove
411 roofs shall be inspected p an inspection, I ag
if a roof is installed without first obtaining
all new materials for inspection.
Date
Applicant s to be Class'4914, or better
Signature of
All roof covering