03010080 CITY OF CUPEW11NO
BUILDING DIVISION PERMIT CONTRACTOR-INFORMATION!*
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BUILDING ADDRESS: GIACALONE ELECTRICAL SERVI A!'&di NO.
10078 IMPERIAL AVE 03010080
OWNER'S NAME 6300 MONTEREY RD. APPLICATION SUB DATE
TAYLOR WOODROW HOMES, INC. 01/14/2003
ONE'
(408) 842-9655 SANITARY NO. CONTROL NO.
ARCHITECT/lINGINEER: BUILDING PERMIT INTO
BLDG ELELT PLUMB MECH
{mmu00 LICENSED CONTRACTOR'S DECLARATION �� O
e U F I hereby affirm that I am licensed under provisions of chapter 9(commencing Job Description
<z wo�nSecti�n700(fafDiviainnSofdeBusin�ss dprofua...AACde,and mylicenseix pppip�,n� ��, np
Fq= morn rona�dtlyrhe TEMP POWER POLE (200AMP METER'0MA°tN}ba�®
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� ¢ IundcrslanJ my pl nes shut Mused as puM1lic(recmds JAW 14 2003
dontu
w316„t- LiccnuJ Pndcssional
FLLyag OWNER-BUILDER DECLARATION BUILDING n
At 8 a Y I hereby affirm that 1 am exempt from the Contractor's License Law I'Ur the BUILDING
a—00 following reason.(Section TIDLS.Business and Professions Gde:Any city or county
wa which requires a permit to construct,alter,improve,demolish or repair any structure
Fir poor In Its isseance.also requires thcapplicint Imsuch pramiuulile aligned statement
<
that Chapter S Ft. Floor Area
ni n d 9 $14flGttion
s F (tot he is exempt therefrom
711 00)she
basis
r nRW Busaged exa and Professions fide)or
a�� that he u exempt mcmfnrm and the basis fur to alleged cxcmpdnn.Any violation of
Section 7031.5 by any applicant for a permit subjects the Applicant o a civil penalty of
not more rhundred dollars($500). be
roan Eve Occupancy Type
01,asowner Of Inspmpeny,ormyemPI(ryeSwithwagesmt irsolecompnnudon.
will do the work.and the stomach.is not intended or offered for sale(Sec.7016.Business 183 —
And Profnssions Code:The Cnntracmr's Licence law does not apply to en owner of 3 04 - ROUGH �� tqI T&ALtIODS
property who Wildsre
With,or impresses theon.and who doessuch work himself or through his
own employees,provided that such improvements art not intended or offered(orale.If,
Wmvcver.he Wilding or improvement is sold within one year of completion,me owner-
Wilder will have me Wrdcn of proving Nat he did not Wild ser improve for purpose of
All
0 1,as owner of the property,am exclusively contracting with licensed contractors to
ceconstruct the pmject(Sec.7(M.Business and Profess ns Code:)The Contractor's Li-
nse law docs not apply to an owner of progeny who Wilds or improves thereon,and
who caramels for such projects with a contractions)licensed pursuant to the Contractor's
License L.
Ell am exempt under Sec, ,B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby a1Errn under penalty of perjury one of the following declarations:
I have and will maintain a Cerin icam of Consenuo sel6insum for Worker's Confirm
sation,as provided for by Section 37W of the Ichor Code,for the pcRormance of the
work for which this pernut is issued.
0 I have and will maintain Worker's Compensation Insurance,as(squired by Section
3710 of the labor Code,for the perhrmance of me work for which this permit is issued.
My Work Compensation Insurance camicr and Policy ymM,are:
ca 'ere
Ai
(.t.bRke2i PnW l /35 - �
CERTIFICATE OF[XEMPrION OMwORKERS'
COMPENSATION INSURANCE
(this section need not W cpermit is if the peris for one hundred dollars I&100)
,or less)
I cattily that in me performance of the work for which this permit is issued,I shell not
employ any person in any manner so as to become subject In the WorkersCompensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:IL after making this Cenilicale of Exemption,you should
become subject to the Worker's Compensation previsions of the Lanny Code,you most
Oz unmoor no comply with such provisions or this permit shall W deemed revoked,
zONCCONSTRUCTION LENDING AGENCY
I bemhy allirm that mere is a eonsuuction lendi ag agency l or the performance of
04the work for which min permit is issued(Sec.3097.Civ.C)
G.1 Q Lender's Nana
7 z Leadef's Address
U 0 1 ornify mad 1 have reed this application and sum that me abuse information is
11r correct.l agree to comply with all city and county ordinances and sure laws relating to
QU Mbuilding construction,and bunchy monriae representatives of this city to enter upon the
Fave mentioned property for inspection purposes.
LI. (We)amen m cast,indemnify and kith hannloss the City mCupcn, against
rn
liabilities, costs indexpenses nifyand lar may inany wayty Of CuertinoaidCity
V z mco cc of the 6;nImn V is permit.
S C UNDF.RST AND WILL COMPLY WITH ALL NONPOINTIssued by: Date
S Re-roofs
pit anUcnmmcur
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Itheap icant or future Wilding occupant store or handle havardous material
a�defined y the upeninn Municipal Code Chapter 9.11,and the Heald and Safety
We.se y"zs .xa'! rNo All roofs shall be inspected prior to any roofing material being installed.
will the aplocation,future building ocet ant ase e If a roof is installed without first obtaining an inspection, I agree to remove
p Area
a ordMana which
^ mit hamNnus air ttmumiwnu as defined by the Bay Arca nir quality Management
Disu'icty all new materials for inspection.
0 yes L.INo
1 have read the W/Mous materials"moments under Chapter 6,95 of the Calin or-
niallealth&SWctyGak.S ...25N)5, ,33and 35534.1undersundthmifde building
dors naso a¢pant tha y resfamsibiloy a,.'air IM nrcuhant o1 the
regmmme : u be norcenificamlr( upancy. Signature of Applicant m /t/. Date
o' sora I ri,,d a t I Data All roof coverings to be Class "B" or better