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00100057 CITY OF CUPER'[INO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDINGADDRESS: VERMI T NO. 00100057 22393 RIVERSIDE DR OWNER'S NAME'. APPI.ICA'I'ION tit f A h PEN CHANG LAI 1. 6/�00� PHONE: SANITARY NO CONI'ROI-NO, O ce] AKCHI'TGCTIENGINIi13R: AUILDING PERhil'I'INFO aIt[.[)(; IiIjfcl' 1'L11MB MECII 6ti IJ L_d I-:1 11 F 6 i x LICENSED CONTRAC I OR S DICIARAI ION - Job Description OL p In by Il hat licensedud p sof rp Che,9(ra:m' i e' ng F: imS I )000 fD 3 flhe Bn nli fexsi nee and nYl cense ani PATIO ENCLOS. PRE—FAR �zW2 Littneoe Cf i hvV-I—/� # `�— O le _4/ Cunuvrnnr y 3 a m ® 7 AKCI{I I F-T'S D{-CLARATION F- g 1 unde,la y mann.hull be tad as public reooms . i c00 Liecmal Pmtneinnll X o._ OWNER-BUILDER DECLARATION m-w I hereby a'fnn'['a,1 um excmp'lined tbu Conuuumi x License Law for me F Z S fallowing neon.See, n 70315.Business and Itofeesions Code:Any city or county - -s p which require,a front,lir donee,u11c,improve,demolish,or r,,air any sumlmm• 6 et prwroo it,Issuance.u6n rcyuine,the d,pli,ml for such pemtiuo file asigncd e,at anvat the,he is licensed penal rlathe pooraewal the Commaors Licenn Law lChapfero Sq. Ft. Floor Area Val (eanameneing with Section 70S),of Division 3 of Inc Busme,and profession,Calc) or mal he is caempt Ihercfr tar and the ,is tau the alleged exemption.Any.violation of'Sca inn 70315 by any applicant fin a wason wbject%tau applicant in it civil penalty ofno,marchad five hundred del lar,($5011,). APN Number Occu . cyType Of.as awnc"Athe pmp,ty,or my cmployeeh with wages as meo-..ole eatopemation. 35603035. 00 ,ill do the work,and the.weture is out intended or altered Gu sale(Sec.7044, Business and Pmfcsaions Code The Can racer's License Law does nor apply m an Required Inspections owner of military,Who builds or mPmvcs thereon.and sent)does such work himself 101 — FOUNDATION or through his own en'ployces.provided that such improvements arc not intended nr offered for sale 11,however,the building in,improvement is sold within are year t)f 1 02 — PIERS .mnoledfnr the n,va—b vk'r will have the burden of proving that he and not build or .. nee paH"rs" 1.03 — UFER 01.asooneronheproperty..aoreacrosivelyeamracbngwithlicensedeon'voIt, 1.04- — REBAR wconsumes he Pon,,(See.7(94,Business aad lard sniom Code:) He Contruntodh eense Law([ties not apply to an owner of property who builds or improve.memo., 1.05 — ANCHOR BOLTS and who connotes for such profms with a contractors)licensed pursuant to she CmnraetmsLitemelaw. 1.06 — SEWER d WATER 0 l am eacmp'under Sec. .H x p C for this reason 202 — UNDERFLOOR PLUMBING a,n`r ' WORKER'S COMPeNSATION DECIARATION 203 — UNDERFLOOR MECHANICAL_ I hereby ahra under perall,of perjury one of the following declarations: 204 — UNDERFLOOR FRAME 0 1 have and will maintain a Ceniflcale of Consent to self-imam for workers 205 — UNDERFLOOR INSULATION Compensation. as provided for by Section 3701 of he Labor Crile. for the ^01 — ROUGH PLUMBING serf rravoce of wars for whim his penal is I..'ed. 6 0l have and will maintain Woder'.Compensation Insurance,as required by Section 302 — TUB & OR SHOWER Out of the La ,r nae.for the performance of the ware for,mien this permit 1, 303 — ROUGH MECHANICAL ..sued.My Workers Compensation Inwmare carrier and Policy nanbef am: policy Na: 304 — ROUGH ELECTRICAL_ CERTIFICATION OF EXEMPTION FROM WORKERS305, — FRAME COMPENSATION INSURANCE IHissecdanneednornecampletedifthepermitisforonehundreddollars 30fr — HOLD014NS (SIW)or Inst 307 — INSULATION I eer0y that in the pedbmence of the work for which this permit k issued.1 308 — SHEET ROCU shall not employ any person in any ni yr as ill b come su to the Worsen' caa,pemae�s�cab, f i DD�'n`r 309 — EXTERIOR LATH AppBcam A�- a^i NOTICE TO AP ICAN I:ILae!iflong his Coliheme of Exemption.you should 31.0 — INTERIOR LATH become subject on the Workers Campemaim pow Wo.,of the Lahr Cale,you met p C curbsdncompy an such pravivinosorthis pennitshot]mdecided revo/.w. 311 — SCRATCH COAT Fla CONSTRUCTION LENDINGAGF-NCY 313 — ROOF NAIL_ > 1 hereby affirm but them in a construction lending agency for me performance onG — the work Cie. 501 FINAL ELECTRICAL ENERGY 1 ,'] Lender's Name = z LcuderhAddress 502 — FINIAL PI_I-IMBING ENERGY Iverify that I fair mad this application and state thanhc above information is O ©�/ 503 — FINAL MECHRNICAL ENERGY :r. F correct.I agree on comply with all city and eounty ordina ordinances ad emtc laws reading C 504 — FINAL BUILDING ENERGY m building amsuuaion,and herehy munnizc reprmenmlivesoflis city,.ever upon he aMrvWe)ti'a n.pme.ny for inspection puHane. / 505 — FINAL ELECTRICAL F G eWelagree t,cost indemnifyand Ieeph may int he waoftivenpa again' 106--,6--, Z liabilities,judgment,fthry and i n of which may in any way active against said u J 506 — GAS TEST f, z APPLICANT UNDER he graining D this permit. APPLICANT EGULATIONSN—DSA—N/D�-WjI/LI/,CO�MPLYK—'ITH�A/LLNOp�IN^ra Issued by: SF17 — FINAL PLUMBINGDaIC Signamm of A m� ( clru�_/MC O //Dale(/— Re-roofs _ HAFARDOUS MATERhL MC 'URE Yp 509 — FINAL GRADE u5u me almbennl or stare,acedias acaapam stare or handle lecvdnas rmamrial T e of Roof as defined by he Cuperino Municipal Crile.Chapter 9.12.and the Health and Safety 510 — FINAL FLANNING Calc Section 25532(x)' O Ycs 0'No All roofs shall be,,%If3ccteci installed. Will the applicant or future building ccenpaat use evuepment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove emit factitious air contaminants as defined by the Ray Area Air Quality Management Dihrdml all new materials for inspection. Applicant understands and will comply with O Yes ON. all non-point source regulations. I il tend rbc hazardous materials requirements under Chapter 6.95 of the California Health h Safety Code,Sections 25505,25533 and 25534,l understand the Bthe building does not currently have a tenant.that it is my respnn.siblity to notify the - occupant of the requirement amen usd be met P u to issuance of a Cerifcae of Overtrain cy. I Signature of Applicant Date Owner or amAadzed agent -- Dale — All roof coverings to be Class "B•• or better