00080193 CITY of CUPRRTINO -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO. ,
r
OWNERS NA4EI0367 HENEY CREEK GLACE WESItiHURE RlJUFJfl1LjAPPLB:xlo , 3
ONE1 CHES SHOSTAK 5869 WINFIELD
— SANITARY N . / d )al
o e y ARCHITECEENGINEER: (,40B)629-23 01D BUILDING PERMIT INFO
O BLI]G ELECT PLUAIB MECII
w
y LICENSHO CON I'RAC'roRs DECLARATION Job Description y_ I hereby amrm that into licensed ander pmviono,of ChaPm19(mul ntencing
Fu,Fw with Scaion]B00)of Division Jofthc Business anJ Professions Cashemad my license c _
is in full Btme and effect
.
c e a License Class Liu.p
a°i✓y ante commuter REMOVE SHAKE/INSTALL CELOTEX PRESIDENT11
ARChall be u"e DECLARATION
C u--m I understand my Plans shall be used as public reaNs ,
ca iN
O O Licced Professional -
a. mz OWNER-BUILDER DECLARATION
mow 1 hereby affirm that 1 mal exempt from the Commumr's License Law liar the
1—Y a following renam.(Section]031.5,llmines,and Profession,Cale:Any any or county
r m which requites a permit m conswct,2her,improve demolish,or mean any structure
i3_ ptionoite issuance,aim requires the applicant for such pcnnit to file a,igna,bttani
that he,,liven,edput,aaatmmepntvi.mn,athe coama„osLicense Law chapter 9 Sq. Ft. Floor Area do
Icmmnene ing with Section 90X01 of Division 3 of the Businca,and Profit iota Cole)
or that he is mo mpt tharcGnnt and the bnsl,far 0e al lial exemption Any violation
of Sceion 9031,5 by any applicant fur a permit subject,the applicmn ca civil Iaenity
ofnatill srethan rise hanArcddapar,S50m APN Number OccuIl (7b -
01,as owner of the property,or my employees w'nh wages as their sole comPenwition.
will do the work,and the stmcmrc is not intended or si fstM for sale(Sat.7641.
Bneine,n and Professions Code:The Conmacmr's License Lawdoes not apply to an 34243927.Falgbired Inspections
r of property Who build, improves bureau,Boil who does such work himself
or through or through hie own employees.provided that such improvements are not intended or
offered for.tale.If,however.tlm holding or improvement is sold within one year of
completion,the ownerh d huddler will have the bunlen(it timing that he did ten build or 305 — FRAME
.im "clinpurpa,eaf,ale.). 307 — INSI-ILATION
01.a,m,neranbepntp y.ait,asesu,i,elycommon,withfieersadcontractors
it, 60F. - ROOF TEAR OFF
av,m t the pmjaW
t(Sec.]6 ,Business and Profusions Cale:)The ContContractor'sor'
License Law does ant apply to an owmer afp.,ay who builds or impm,e,thatcun• 602 — ROOF PLYWOOD NAIL
and who contracts for such imjats with a omwgm(,)licensed pursuant m the
c aouarsLicenseLaw. 603 — ROOF BATTENS
01 am v,cmpi under Sec. ,B&P C for thin reason
Owner Date 1 504 — ROOF IN—PROGRESS
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Ism alt,of perjury.,at of the following declarations:
7 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Section 3701) of the Labor Cada., for the
perinrntance of the work for which this permit is Ismail.
01 have and will maintain Worker',Componeminn In....ame,as required by Section
' 37M 01 the Labor Code,Poli the perfamona of the wok for which this Pmouil Is '
i,wed.My WWrrker's C rmpensmum Insurance carrier I I'aliry/ny_mbcr are -
C.aricr; 1 r 41CP,tllcy Nn: O, _ V`re
CEKrIFlCATION OF EXEMPT ION PROM YORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is liar one hundred dollar
(E HN0 or less.)
I certify that in the(wrlimmance of the work for which this permit is cwed,I _
shall not employ any pcnmi in all,manner sat as to become subject in the W..ken'
Compensation Uses of California.Date
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
Obecome subject n)the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such pm,Non,or this Permit half be deemed,evukal.
Z �
V] GDN3TRUCnQNrodus.N n AGENCY
a 5 hereby
amen that dere 1,t.eased(Sm. Lending ngeacy far the ped;Intvtma
Lund work for which this Iwmlit is I„uul(Sear.Jlm],Clv.C.1
0. Q Lender',Name
;D Z lendcr'n Address ,
U 1 certify that I have mad this application and state that the above information k
correct.I agree to comply with all city and county ordinances and slate laws reining
C.7 to building construction,and hereby mnbaris,representatives oRhls city it)emer,upun
the above-mentioned prnperty for inapecban purposes.•
ti 0, (WOelitcc lettuce,indmnnily and kap hamuless the City of Caperino ngaint
N Iiubilhim,judgments,costs and o Tuatw,which only in any way aceme bound,aid ,
V z clry In CANT UNDERSTANDS
AND
this eon t.
APPLICANTUNDERSTANDS ANDW COMPLY WITH ALL NON NT Issuedb Date l/
5 CE A IONS. �Z �Q y
- nm um al ApphcantlC "n' Data. Re-roofs -
HA UOUS h1Al'ERIALS DISCLOSURE
w,ll me appraam.umere lmudmg ucaupam ware err handle humudet,mmslal Type of Roof
as delined by the Cum inn Mmu,.ml Coda.Chapter 9.12,cordite Health and Safety
Coda Satiom 25532(n)'1
'Cl ye, ElNo All roofs shall be inspected prior to any roofing material being installed.
Will tau applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hamardous air conla mations as defined by the Bay Asa Air Quality Management
District^ all new materials for inspection. Applicant understands and will comply with
MJ" ElNo all non-point source regulations.
I bane read the ha,armas materials retrviraaetn,ander Chapter 6 9 of the
it the buil Health&Safety Gxla ave a dc25505,ant,tht itis y te"o'.1andmrsandthe
it t.....mdingd«sontnneon,which
astF,lout itis my"manceiof Cunfidile he
of LILY/� vJCO/
ocagnlm of the nyuiremm�ts which must be ten print m issuance of a Certilicute of
°Cepa"`y' Signature o pp C• 'Date
0%net or amhodted ng cut Data All roof coverings to be Class•`B"or better