00060185 (2) _ .feITY OF CUPEW11NO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
Z'QIIUILDING AUURISS: PERM 1'1'KO.
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UK�ER'ti NAMP: A PPLICAI'ON SO I I IIA I ��\)
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IN
HONE: SANITARY NU. CONI ROL NO.
25-3- 1706 LX ekti 1.
❑re V. AIi III 2CDENCl1NfilHR: BUILDING PERIMIT INFO
O O /��/t/] (y� // IILI)it ELECT - PLUMB PCH
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LICFNSED CON'rRACIDRS lll!CI,AlkXIION' Job Description
✓m—+ I hereby affirm Inas 1 am licensed under pros Llons of Chapter 9(commmociag
with Section 7")of Division Sof the Business and Pmfcsionx Cod.and an,liven,
I'm full C�fjoD/rcase'm'andg el Cf0 IJCp_
cC/ek. mncCN3 n11cl-ARATON
Al. public reord(sm
pOLanwJ 1'ndcsinnul
ce z OWNER-BUILDER DECLARATION
'lS N I hereby aRnn that I am exempt fain the Conlmctor'a Liccnw Lew for the
F>�' IiJ owing rtns,n.IScctinn 9(1}L5,Business and Prole,,ions CNV•:Any city nr county'
aC when I -' p u e i........ Are, Ir I I:h ttpi y;tmuure
i 3 pirkarto itsI: 4 r the applilnuil fin,allapIranNas filea so,old ate Wena
that he is 1c ookall pursuantl the pativianar,ofdrc I t r License La (Chapter9 Sq. Ft. Floor Area luation
(eformemi all i,h Section 700(dof Dovikkm 1 of the Hmirn,, ad 1 f s Codc)
or mm by is clean,d rn1n n of the ht,i,s for the allcyml tAtininio. Any vioUlion
of Section 911115 by any appllcan I'or a scant Subjects the nPPllcnut to a civil penally -
of Nat more than fire hundred dollars($500). APN Number Occupancy Type
❑I,as owner of me propeny,,,my employe,'with antics as mcir will eompcnxmion.
will do the work,and Jct snncuoe is not inmaded or eUcred Icor sale(Sec.91"4.
Busincsa and Pml,ssiuns Code:'rhe Commemr's License Law does not apply to an Requir
ections owner -
of property Who hands ar improves thereon,and who docs such work himself
rthrough his own employees.provided that such improvements are nor intended or
I'li. 1 t .v -m h Id' 6 p a a n Id within y ar of onpla cl h W Ile II rd I.. Ibtld dime lair 'mp c f p rq f l )
❑I if the property, I " lycontracting with fl J contractors l: /
hh lu ode prcyvl lbc.9144.Bnxma d Pr.,Ic......rvCoal:) I ICalulls
Lice,,la,c does not apply m ua owner of p.,Nnl who builds,,improves Iherc,n. 11
and aha contracts for such projects with a commmogs)licensed Pursmam to the V
Contractor',Licca,Low.
E]I no cxcmpl major See. ,It.@ P C for this reason
Lane, Dale
WORKER'S COMPENSATION DECLARATION ,
I hcrchy chant under putty of lwrj.,y one tyres following 0eclumdonv".
7 1 have and will maintain a Certificate of Consent to self-in,me far Worker's
bmpcnsation, as provided I'or by Section 1900 of the Labor Code, for the
per(onounce ofine a ak for welch this pco,df is IsmmL -
LVt'have and will maintain Worker's Compcnvrion Insurance,as required by Section
15G1 of the Labor Core.for the perfommace of the work for which this permit is
sued.Myr Warke,�'a�C(umpenwtiin 1-mance carrier mal PPolicyy annallserraare: n Qf
Lamer:lQWn/! Policy No,d/C_�1&"13� /0 / '
CERTIFICATION OF EXEMPTION FROM WORKERS'
Cllhll'ENSAI'ION INSURANCE
('ans section need not la completed it the pemhit is for one hundred dollars
($100)it IessJ
I verily teal In the pedoroumce of the walk far which Ibis pcnn l Is issued.1 .
shall not employ any person in any manner w as w become subject to the Workers'Compensation Low, if California.Date
Anal cark
NOIILH Ill AIl1ICAN'r.11. lifier lialsoll;this Clodfill"or ilikerip6loo.you should
Z Ql+ FJ n dcW k C polr p an(d h C you and
mr- ' cpalthh p pt hall (lJd ed. Z,amQ
/ /V/
CONSrRUCl LENDING AGENCY �
!"I I hereby cram,that mere is a construction Ieadimg agency for the perfora ance
'mss of me well for which mi,pemdh is issoIII Ise,.3099.Civ.C.)
y G Leader,Name
Q z Leader,Address / 7 / 7 2-
U Q 1 kri ify that I hove .it Illi,application and sale that the above Infnrn,aaian is
Is, E.. coned.I ogre,a,comply with all city and county ordinances and lam laws relating I�e
Q V a,huildingn nstrvctinn.anti hereby awhnirc reprcwnmtives of cis city to mar spat /
Fry7 Ihwmuve.mcminncd propery for Inspn,ion puTows.
y (We)l to toe.indemnify and keep harmless the City.,]Called agm a,l
h
LfL
juJSmrnimus and expen,s which may in eny way acerae againa snitUz ofthe granting of mit RSTANUS AND OMPLYWRHALLNyINIxy�T Issued by: Date
IONS. �'/'/J���'7�[/�,/.ash can Canmanr 1'"" Re-roofs
I IAZARDOUS hIATI?RIALS DISCLOSURE
Wulmeappauml nr rmme building rccvPaat store or handle havardoas n;aaedal Type ofRoof
ns defined by the Con,nion Municipal C(dc,Chapter 9.11.anti the Health and Safety
Cede.Section 25532(ifis
O Yl, ro All roofs shall be inspected prior to any roofing material being installed.
Will IN.,li,amar fmme bail:Hn,recnpanl use ellipse u."lcvices wh'ic'h If a roof is installed without first obtaining an inspection, 1 agree to remove
emit ha'oush lair c,nlaminano.as defined by the Bay Area Air Quality Managemenh
)i,taet? all new materials for inspection. Applicant understands and will comply with
outs �No all non-point source regulations.
I have read the haeardo.,materials r,.irmncnt,under Charier 6.95 of till
Cahifamak Hcalm .all,,Cada Sections 25505.2551]and 25574.I understand that
if the No fangdr s )currently have ahmon n1lo"In,
aibiliry to notify the
ecapanl of d, 'eyu c Sun..which nntxl heofuC"obeatnof°acopaa`YnSignature of Applicant Date
Ownmor Imm,a......age Ilam All roof coverings to be Class "B"or better