00030087BUILDING DIVISIONaQ TsRACTOO R I F + tMATI t N: l/
PERMIT�ariee }�
❑NG n'ADRESS: � iz f e
LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Se Lm.9000) of Division 3o fine Buaineia and Pmfeaaiau Cade, and my It.. is
in full Loma aM effect.
license Clea Lie.«
Dam Convector
ARCHITECTSINused DECLARATION t.
1 understand my plans shallill W u public meads
Licansed Professional
OWNER -BUILDER DECLARATION
t hereby aRm that 1 an
exempt from the Contractor's License Law for the
following mason. (Section 703 1.5, B normas and Pmfenione Code: Any city a county
which reagins a permit m comwa, alter, improve, demolish, or re air any a..
pint to it. issuance, also reports the applicant for such permit to Fit e a.igmalstatement
that he is licensed punwnno the pmvisions of the Committees License Law (Chapter 9
(commencing with Section 7th ) of Di vision 3 of the Betimes and Pmfeuiom Cods) or
that he is exempt therefrom and Ne basis for On alleged exemption. Any violation of
Second 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not & than five hundred dollen ($500).
are owner of the pmpers , or my ernpluycer with wages as their,tile compemuion,
will do the work, and the emanon is nm intended or offered battle (Sec. 7014, Business
and professor"
Code: The Contnnor's License law door not apply to an awn. of
property who builds or improves distant, .d who does such work himself or through
his own namoyeen, provided that such improvements one sea intended or offerM for
cele. If, however, 0c building or improvement is sold within one yeerofcompl.ion, the
owmr.WBde, will have the burden of proving that he did am Wild or improve for pur.
you of sale.).
❑ I, as t to of the proper,, ,f exclusively contracting with:carred convenor to
construct Ne project (Secapply
7W, .a, of red limproperty
M builds
COAs:) The Convaremb red
who contracts
Law coos nm apply je an owner of pmpeny who seolds or improves thereon. end
whonse La. fw such projects with a canmcmgq licensed pungent m the Contmcmfs
License law.
lore exam turwer gee.�g�/� /� BffiPCfo Nrs wan
Own. ! /_ \Cl�� Dan
WORKER'S COMPENSATION DECLARATION
1 hereby a0irm doctor penalty of pe jury oro of the following declarmiau:
❑ I have end will meinadn acenifcam of comeat to relbimun forworkei s Compere
cation, as Provided for by Section 37M of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurama, m meuited by Section
37W of the Labor Code, for the performance of me work for which this permit is issued.
My Workels Computations Insurance carrier and Policy number am:
Carrier: Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This station need not becompleted ifthe permit is forom hundred dollen ($100)
ce Ica.)
1 certify that in the pentorm^nce of the work for which this permit is issued, l shall
not employ any .on in any, manner so m to become subject a the W^rkxn' Compere
various Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If. after meting this Car ifecam of Exemption, you should
become subject to the Worlds Compeoutian provisions of the Labor Cade, you must
forthwith comply with such provisions or this perrnit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby Mem that then is a construction lending agency fa the perfommce of
the work for which this permit is (Sec. 3097. Civ. C.)
L.cMelr Name w
Lewes Adan,
1 cerlfy that 1 have read this ispplicninn and state Nat the alseve information is
correct. I agree to comply with all city anal county adimncea and time laws bell ung to
building emmuchon, and hereby aothodze rtpmaenLow. of Ibis city to enter upon the
ithnve-meramned proper, for inspactom pmpoem.
(We) agree m atve, indemnify and keep humleu the City of Cupenim against
Babilu es, judgment.emu and npensee which nay in any any accrue eget.. said City
in contaminate of die gmmut, of this permit.
APPLICANT UNDERErANDS AND WILL COMPLY WILD ALL N04—MINT
SOURCp .O .ATIONS.
Signammuf AppliuMContowtor�/(
HAZARDOUS MATERIALS DISCLOSU
Will thicpplicam, or future Wilding oocup.m an. mime hazardous material
as defined by the Copenino Municipal Coda Chapter 9.12, end the HmW .W Safety
Coda Section 21532(x)? �j/
❑ Yes
Will the applicant or future Wilding occupant use equipment or devices which
emit harandous tip contaminants as gpfr ed by diic
e Bay Arca Air Quality Moomfu m
District?
C][/
Yes
1 have mad the N.dm, mammal. mNncromos, urMer Chapter 6.95 of the Cali.
forma Heads & Safety Code, S.tiom 25505, M533 and 21534.1 understand that if the
Wilding dose rrentlyhevea mato di.r i nn're, oromiliryryryttt�yy��}}}ggqqqqnnn��nnnreify pre occuFort
afmm 1.whic� 'o usuance oftf 9pf�.my
Owmrar authonzeJ agent /age x Dam
v
Job Description .
W -Z"
a rtfa L'i j'4Wr7,,�Q�lceu, cmc
Sq. Fl. Floor Area �tion
3 G ^ APNN
09 rnbeOccupancy Type
G
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
1 agree to remove all new materials for inspection. Applicant
underds and willDwith all non point source regulations.
O/A
Signature of Applicant Da[
OFFICE
All goof coverings to be Class `B" or better