02030030 OF
TINO
ct sat DI c my SIONPERMIT CONTRACTOR INFORMATION:
•• BUILDING ADDRESS: PERMIT NO.
10370 PRUNE TREE LA CASTO ROOFING 02030030
OWNER'S NAME: APPLICATION SUB DATE
JACOBSON IRWIN S AND LORA F 1938 OLD MIDDLEFIELD WAY 03/08/2002
PHONE: SANITARY NO. CONTROL NO.
'' (650) 961-8922
❑ ARCHITECT/ENGINEER: BUILDING PERMIT INFO
00 BLDG ELECT PLUMB MECH
u .I C-1 L._) I
LICENSED CONTRACTOR'S DECLARATION
� 1 Hereby affirm that 1 am haan.m ander provisions nrcnapmr 9(commencing Job Description
1=tln o with Seciion7")of Divisio 3of,h,Ru.,inevs na1'ndessioro Code,a Ido,y1imuse REROOF.
In f 11 KC and eRc�
:zea Lin las, !! Lie. ?a� 3
Be i�' t Cunt or
i a O ARCHITECT'S ARATION
I nndentand my plans mall be used z gable records
i d p O Licensed Professional
OWNER-BUILDER DECLARATION
6 M I hereby affirm that 1 am exempt from the Contractor's License law for the
C Z a following omwo.(Section 703 1.5,Business and Professions Code Any city or county $5100
E ❑ which q permit t construct, ' p demolish,or repair any surname
3$ Priv to itsu t o requires thoapplicIma for such Permit to File a signed statement - -.-_ ...
this hm asci purtraint to drepubmisions ofthe
C inncarosm Uw9 �• �31S� WJ
Valuation
(commencing sN secto ]BB) (Dt l orthe Business ce ons Colde)
1 S
or that he is exempt thertfmm and the basis fur the aHcRol a unption.Any violation
-of Section 70313 by any applicant fare permit subjects the applicant to a civil penalty 7��
sof a.( me than Eve hundred Hall IS5W). 30,APN -P'F gE H Occupancy Type
°I,esms arof,ha progeny,or my employee x ith wages Its their sole compensation,
will dothe work.-and t¢-amatare isnot intended or offered for sale(Sec.]OLL,
Business and Professions Code:The Contractor's License Law docs not apply won 601 - ROOF TEARqu�3g�3nspectiohs'
owner of property who builds or improves tbcrenn,and who does such work himself
orered Rwhilown amply p 'ledmetmpnovepmvem r. are act inro year or 6OZ-_„ -, ROOF_.-PLYWOOD- NAIL_
comple for sale IL howc helb h have
s or improvement n diold thin one year of -
completion.me nwmr.amaawnnar�e me,amen,rpm.ns mat be am oat wire we 603 - ROOF BATTENS
Hermosa for parpna ornate.). 604 - ROOF IN-PROGRESS
- --” -' -- -- - - - - ----- ------
_ I;as owner at the pmpeny,am exclusively commaing with licensed contractors to �11�! „ n
°
consimel the project(Sec.70,1,1.Business and Professions Cnde:)The Contioctor's 0�7 L E (�.�,
License Low does not apply to an owner of property who builds or improves ihertan.
f 7 .and who contractsfor such projeca.with a contmctor(s)Reached pimmon.to the-
Conchher Lice _ _ ... .._... ____.. ..- _._ _ M _1
tmnse Law. AR � n/o0n/
_ °1 um exempt sea&,Seca ,B A,P C far his mason - ` 4 `
Ow,L - t.'.. '`Date
WORKER'S COMPENSATION DECLARATION BUILDING
I hereby affirm under penalty of jierjury one ofthe following declarations: -
° 1 hcve'and will'mairmio a'Cmircate of Conserv to'selLinsam for Worker',
Compensation. as provided rar by Section 37W of the Labor Cod, for the
perfomtanee of the worA for which this permit is issued. ,
°I h d will mainiain Worker's Com,anaam�orilnsarancx,as req red by Section
37W of tM1 Lbo Cad f Ne pc fpym in k f which th perm v
,,and M W k Co npe s non Inium etta d Policy
epon y�I be ,,11 -
Lupn Poliy „os30'IfOV .. .. _ ., . ..-c - .- _ ..-...
`/- Il CERI'IPI TION OF E%E ION FROM WORKERS r - - „a„ }
....-. - ._r 'NSPTION INSURANCE' _—__ .... _._._.._____..._.__..-. -------- ...—.._.._..
.__...-. ore lased if the noir .-..~-_•_� _._..__ _ _._...__.___.
COMPO _
'' `(Thissenion need not be�e. _is far one hundred Mims "�) """' " 1?
SI BE)or Icssl
I rectify that iin the performance of due walk for which th•'pe v IS issid;l r I;
emr .,'L,•:r T•' n t--' '__+. -
shall not ployany person to any manner,so as to become subject to tie Workers'
C^ v mi Laws or Calfmt .Date
`^ unt s
-... ...-. . ...
l NOTICE TO APPLICANT If.after making this Cerlificam of Exemption.you should
become iu comply the such
Compensation ortiisp.I, hall the Labor Code,you most
Q 0 (onhwith comply with such Pmvi-- or this permit shall be domed rtvoked.
s '. ._ .... ._. _.. __... ..._ _- -_ _. __. _. _ i .
r
'CONSTRUCTION LENDING AGENCY '
aI M1crcby-affrin that there o mnamn rn kna ng fn the gado'tame i t st
r+
of th k fon h ch this perm t is issued(Site 3097Civ.e.C.)1 "
�.z Leadc sAddreas•
U 0I cannily that l have read this application and state that the above information is
Wo F.t cbreet. I agree tq comply with all city and county ordinances and state laws relating
to building construction,and hemny'authorize apnslntativcs of this city to enter upon
�.-�l the above-mentioned progeny for inspection purposes. _ .
96 1W,)agree to sae mdemvRy and kap harmlc a the City of Cupen no aganst
F. y
liabilities judgment,,c 6 d expenses ht h, y any y garnet said
U.MCityy nc sequence Mtb g.a a,g fthis perms tiV(a (J v
AT LIC NT.UNDER TA NDS AP DWILLCOAIPLYNT"PHALLNONPOINT t' I
0 R �' TI N Issued by: Date
sigtia�t eaYApphnnuenntacwr.' r—•—'"pate Re-roofs
ERIALS DISCLOSURE
as defined bythe Copan oMunicipal Cg occup t store or,handle hazardus met al TypeofROOF -
HAZARDOUS MAT
Will the PPlim t f t rc oviln -__ ... n— . .r .. . ....
' cod Chapter913,and theHealth and Safety w - t '- -
Cash.
aYes°SSI:UI LNS.s. tl s+ r
nV . :,',(+. ., f '_'_e _ _All roofs shall be inspected.prior_to any.roofing,material being installed._
'
Will theppl pant f t eb building occupant use equ Pme to de isx. h If a roof is installed,without first obtaining an inspection, I agree'tli remove
ani i M1 z E conuirmcartts as d r ed by the Bay A ea Ail Quality Management
•oat ct _ _ all new materials for inspection...A_pplicant understands and will comply with
all non-point source reg It anonsx,
6is
Cahromis
e m d the nazam s m t ak qu rc is oder Ch pt 695 of the
ingdo, SofryCud S i x25505litisd3SSJ41 d t dthn /Gem P cad c itim a tly h t that l t. yep of C rfy thef U equirem t xlnchtnust be ma pn'a to rcs cC-f o Centfam ofSigndture of Applicant Date
_ All roof coverings to be Class"B"or better
ath.diledagem" '.'Ij Dae.,Ji. a. .., .t..
FFICOE