04060028 CITY OF CUPERT[NO 'm�i^���� +*�: �+'�_�v �^e� "�""ry`W '�� '�
euao�nc orviswrv PERMIT �CONTRAC�TOR INFORMATIQN:`
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BUILDING AD�RFSS: PEItMITNOO4�O E O O Z B
OW NER'S NAME: PERMIT L'SUE DATE
JOSEF & LEA BR
NE: SANRARY NO. CONiROL NO.
ARCHITECUENGINEER: BUIIDING PERMR INFO
aLDG ELECf PlUMB MECH
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u00 UCENSHDCONIRACIOR'SDECLARATION �
�� I hcrcby a(Grm Na�1 am li¢�ucd unJcr provisions nf Chepmr Y(commcncing Job Description
� v;msecuu�)ax�)oroiH=fonJoruneuvnessviarrar�ssiomcoae..�wmy�ko�f.
��d ��r�nm�.�a�rca� ADDITION ON FRONT OE HOUSE
j'q_ uconscass. Lic.A
;�o o=� c������ MASTERBATH REMODEL/SKYLIGHT
"� ARCHI'IECTS DECLARATION �
�S I undewnJ my plons alull Ae wed n public rturtds
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;Q� 6iccnuaRufcssinnal
� OWNER�BUILDER�ECLARATION
.��f I hcrt�y aliem�hal I em uemp�fmm Nc Conuanofs Liccnx IJr for�M
p o fallnwinp mssoa(Sccuan]IU I.S,8usircss�nE Pra(ccviam Cak:My ci�y or county
°$� which rt4uires�pcemi�io rnniwct.tlmr.impmve.dcmolish.nr rtpoir eny nmaure
pnoruiiuissmncc.alwmquiresNcapplium(orsuchpc�miuofilcasigncJsu¢mcm
F�0 NaihcislittnxJpursuammNcpmvisia�uofNCCanuacmr'sLi¢vefaw(C��pmr9 Sq. Ft. FloorArea V2�U��QQQ
z� (commcncingwiNStttion)000)ofDivisionJo(Nc9urincssanOPrafecioiuCotle)ar
y�$ Nai I�e Is eacmp�Nertfrom�nA Ne buu for Ne�Icaed eumpuon.Anr vlolauon a(
Scnion]�31.Sbyanyepplicmtforepcfml�subj¢uNcapplicmnoacivilpenaliyof ppNNumber Occu anc T
no�mom Nan five hundrtL dolhn(5500). P Y YPe
❑I.uownvafNePmpmY,mmY�ploycrswiNwgesa�Neirwkcompew�lon. '36z20�Q5 . �� '
will Eo Ne work,enA Ne iwcwm ii not imm�deA oroRcrtC forielc(Stt.]06d,9udxu
anE ProGuiov CoEe:Thc Conmcmr's Littrta I�w dors not eppty m en owner of - R0L]UIiOd TIISPCCII027S
pmpeny wha W ild�ar impemv We�mn,ane who dassuchwmkhimuAf or Uuavdh�u
awn cmployvs,pmviCed Nm wc�impmaemenu m no�in¢ndrA araRurA fmsaleJf,
hawcvcr,Ne builEing or impmvemem i�so1E wiNin one�ev of complcoon.Ne owncn �
builEer will�ave Ne W Nen of pmvin6 Nu M tlitl noi Wi1E or impmve for puryoae of �
alcJ. �
ef 1.u owKr of Uc PropcnY.un uclmivcy canueninp wiN IianscE mnuumrs b
cansuun Nc pmjen(Sec.]OdG,Busincss�nG Prokxtions CaUe:)7Tc Conuumra Li-
ccve f�w Oacs noi eoV�Y�o m awner of pmpeny wha W i10s or improw Nemon,mE
who conuacu for such pmjccu wiN a convamqs)IianxO pursuam�o NeConu¢mle
Licevc I�w. �
❑lamevemp�nIOerSec. ,B&PCfarNisrtazon
owk.i /Y�R"QO �i'1 LP t�-2_ 62 �
' W RKER'S COMPFNSATION OEC RA ON �\
IIKrtGyeffirtnunderpcnal�YofperjuryareafNcfollowingdccluatioiu: ' �
heve ond will mainuin a Cenif¢o¢ofCoruent�o xlf-insum for WdrYetsCompen-
on,ss pmvidca fw by Stt�ion J]00 of ilx l�bor COEe,fm Ne peRo�muxx of Ne
wmk for whic�Nis pertni�ia iisucd. �
❑1�avc an�will mein�ain Wurkcr's Compcivation liuunn¢,ss icyuire0 by Scnion
3000 of Nc fabor Code,for Ne pertmm�ncc of Ne woh far w�ic�Nie pnmii i�isue0. ' .. �
My Workeh Campewuoa I�uwana eartiu enE Paliey number uc:
Caerier. Poliry No.:
CERTIFlCATE OF EXEMPf10fi FltOM WORKERS'
COMPENSATION INSURANCE
ei*��um neea nu�M1e enmym¢a irNe pefmn I:ru.one nunurca aon.n(s�m)
nrlc�sJ
1 cenify Na in Nc per4vmencc a(Nc wart for whic�Nis permit is issuctl.I shJl nol
cm0loyanypersoninmymmnermubbecomesuEjaimiM1eWartrrs'Campcwuon '
Laws af Califomia.D�u
ApPlicam
NOTICE TO APPUCANT:IL ufmr matinp Nis Ccnif¢a¢af Exemp�ion,yrou shuulJ
bttome iubject b Ne Woherl Campciwuon pmviuons of Ne L,�Mr Code,you muv
.J,z, faMwiNeamplywiNsuehpmrisiovorNupermi�s�allbcOecmWmrotrG.
'�O CONSI'ROCfIONLEN0INGAGENCY
[—� IhertbyNrm�ha�Nertisaeort�we�innlendinia6enryfoeiAcpcefurme�eu(
G' � Ne wuek fm whie�Nis peemi�u iuurA(See.JIM.Civ.C.)
R1 Q LenEcrs Nvnc
� Z Lender'sAadrtsi
V Q I�enify Nat 1��ve rtad Ni>>pplicuion vW su�e Nai Ne�Eo�e infortn�uun u �
� F cortca I�yrte�o camply wiN�II ci�y�nd counry oNinu�ces an0 suu laus mhiing w
pU buil0ingconswnion,anJpembyeuNonmrcprrxnuiiresofNisciiyiocmcrupnnNc
ahavcmenuuned pmpcny for impeeuon purpam.e ��
F y (Wc)a6�e m u�s.inEcmnilY Nd tecp h+rmleu iAe Ci�Y o(Cupenino��airts�
y Iiabili�iu.luE6�nu.ewumEevpenseswM1ic�maYinanYM'+yaeeeue�6ainnuiECiry
V,'Z m quenccof�hepnntineafNispcemil.
�—' APP CANT UNDEftSTANDS AND WILL COMPLY WITH ALL NON�POINf Issued by: � Da[e
0 CE�GUL�TION�O��p
L�°� '�� �� Re-roofs
Sigmt ofAp ianUConvaaor De4
HAZARDOUSMATERIALSDISCLOSURE TypeofRoof
wll Nc�pplieam w fu�urc Wilding oacuqntuoee m haMlc huaAoui me�erid
u EcfineE by Nc Cupenino Municipal CoEe.CTap¢r 9.12,�nE iAc Hra1N ind Salcty
COL[,$CC4Dn 2$$JZ(a)?
❑m �gN„ AIl roofs shall be inspec[ed prior to any roofing ma[erial being installed.
If a roof is ins[alled without first obtainin an ins ec[ion,I a ree to remove
Will Nc�pplinni or Powm Uuildinp occupam vu eyuipmcm or Ccvim which 8 P g
t haraNnus�ir conuminanu u JcfncU�y Nc B�y Arca Air Qualiry M�mgcmem all new materials for inspec[ion.
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❑Ycs �Nu
I havc 2ad Nc pvaNiwsma¢rials rtquirtmenu unJcrChap¢r 6.Y5 of Nc Glifor-
nia HcaIN&SafciyCotic,Sccuo�vs 25N15,355JJ and 255J4.1 un@rsunE�hmifNc huilJing
dou nol curtcn�ly haw a mnan4 IAet i�ii my rtapomi�ilily Io nouly Nc occupani of II¢
reyuia 'nmuvbcma ao,�,��„K�or.c�Nr�,�oroa�P�. SignatureofApplicant Date
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ow��,�,�� a,�,x s��, p,k All roof coverings to be Class "B"or better