06080224 CITY OFCifPERTINO
BUILDING DIV1910N PERMIT
BUILDING ADDRESS: PERMR N0.0 6 0 80 2 2 4
19750 AUBURN DR
ER'S MEPERMR ISSUEDATB
NA :
ANDERSON DONALD LEE 09/27/2006
NE: SANITARY NO. CONTROL NO.
ARCHI ECT/ENGINEER: BUILDING PERMIT INFO
BI DG ELECTO PLUMB� MECH
0
oo LICENSED CONTRACTOR'S DECLARATION Job Description
to 1 herb afmm that I un licensed under proWions of Chapter 9(commencing P
Ju hath Semkm7000)of Divimon3oflho Busineoand Profaasmns Cede.and mylkenmis
in full ran.a rc a / REPAIR FAILING ROOF RAFTERS WITH NEW. 4 NEW
)•�z Lleense Cl a �•»
Contractor ISOLATED PIERS AND 3 NEW CEILING BEAMS (N) ROOF
i Da¢
CHITELTSDECLARA ION
9 I mdenand my plans shall be used o public retards
so Licensed Professional
s Oat I am sUILbER DECLARATION
0 0 1 hmoo .(torte thin 11. aempl from Ilene Convectors e:My Law for me
O D following mason.(Section 7 construct.
Business and ve.de on Code:Any city s county
f$122 which mquva n permit ra ennasum alte+,improve,hpmm Rh,or repair ed mmocal
-i�' prior toits ksnnco.alm requite,me applicant for such permit to rile aligned ststemcnl
ValuA10000
s< than heiauamedpamamlmdteem.;,lalmaan ofiMBummral;Pmfe.wfcharmr9 Sq.Ft.FloerArea
eF4 (comm is licensed
omens 7000)of Division fon Commmoandc.Law((Chapter
$ Nu he u exempt therefrom and We basis for the alleged exemption.My violation of ppN N b
Section 7031.5 by any applicant for a permit subjects me applcant to a civil penally of 31-63 5(��7er 0 0 Occupancy 1I pe
Act more dun five hundred tho1Ws(S500).
I.As,owmr of the property.or my=,Jay=with walla a Web it compewdon,
will dome work.And the ammateAOut macculorarrested far ask(Sm.70at,Bamum Required Inspections
And Pmmp
fe: as Coe:To Contractor,Lin•-" I.w them, OA—oat apply an owof 9 P
property who bu0dsmireprovm dtercon,and who dacasuchwork himwforde augh his
awn emplayen,proNded that suers impmvemmts ase tet Year
of�moneyed(m auln a.
hailoor me buildingtheor Improvement khalt within ons Year ofcoprove fan.r
thin owe r.
of
builder will haw dte burden of proving that he did tet huiW m improve far puryose of
❑1.As owner of me property,am aGusively contracting with licensed con,ncm s m
come=the pmjm(Sec.7044.Business aoe Profession cadet)The Contractors u.
cave Law don not apply to an owner of property who builds or improve Weldon.ted,
who contracts fm such prejenn with aeonuramr(a)licensed pursuant to We Contractors
License Law.
❑1 an exempt under Sec .B&P C fm this moon
er Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury aro of me ftimwing declaration
lon mawill maintain sCenshomeof Comenuo self-fuser,for WarkersCompen-
todon,as provided for by Section 7700 of the Labor Cade,fm We performance of the
wart for which this permit is Wood.
❑1 have and will maintain Worker,Compensation Insunma,u mquimd by Section
3700of the I.bm Code,For the perfarmancaof tae truck for which thispermit is issued
My Worker,Cam and mmanm m and Policy number am:
Cares z r5��Policy Na.:rsy:?62 7�
ERTIFIC TE OF BKEMPIION FROM WORKERS'
COMPENSATION INSURANCE
(Dais inion med Out becompleted Uthe permit is foram handed dollars($100)
or less)
1 cenify thea in the performance of Ute work far which this permit Is issued.I Wall no
employ any person in my manmr an As an become subject to the Worker,'Compenanlan
Laws of Calffamia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cent ate of Exemption•you should
become subject to the Workers Campcnation provisions of the I.bnr Cade•you muss
0Z forthwith comply wdm such pmvlaam or this marritahall he ticomad revekcd.
z0 CONSTRUCTION LENDING AGENCY
[. 1 hereby aBtrm that mem its construction lending agency for the performance of
CL> We work for which this permit Is issued(sec.3091,civ.C.)
W CaLenders Name
z Leaders Address
U Q 1 certify that I have read this application and tete that me above ioroanatiun is
W P torten.I agree to comply with all city and county ordinances and sure laws relating to
CU building construction,and hereby authorim representativescar Otis city to enter upon the
�0. move-mendoned property for inspeedon purposes.
(We)agree to Ove,indemnify and lump harmless the City of Cupenmot agaiml
M limilitksJuigmcnu. seaman "'hi me my way atom sgai of aid shy
Uz mcontegmn of mnvngof thi 11,
^� APPLICA UN STANDS WI OMPLY WITH ALL NON-POINT Issued by: Date
SOURCE G TIONS.
Re-roofs 2—
Si of Ise
HAZARDOUS MATERIALS DISCT.OSURE oars T}peofRoof
Will dte applicant or purism building occupant atom or hawk haute.material
as defined by We Caperton Municipal Cade.Chapter 9.13,and the Health and Safety
SnNon 35533(a)7 All roofs shall be inspected prior to any roofing material being installed.
CYe. /211
Will me applicant or future building=open,um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haverdnas air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Diatrict7
❑Yea
I have mW the havarMasmamdms mquimmenu under Chapwr6.95 of the Califon
nice Health&SalmyC . mac,35505,35333and35534.Iavlersund thmifhe building
dace net cu dy ve a team,that Ito my responsihllity to madly the omupanl mar the
requirement In muax nen °"'' facmifiamoratapmty ! Signature of Applicant Date
A ' /V-IC Q 2 4o All roof coverings to be Class"B" or better
0wner tar m anted sTx: am