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CITY
mo of FSIONO
BUILDING N PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
J
•OWNER'S NAME:
APPLICATION SUR DATE
041,23/2001
'PHONE:
SANITARY NO. CONTROL NO,
ARCHITECT /ENGINEER:
BUILDING PERMIT INFO
r BLDG ELECT PLUMB MECH
I_I o CI u
LICENSED CONTRACTOR'S DECLARATION
I lu th.t 1 licensnl
Job DesCl'IpI1011
reh' affirm anal under pnsv'nlons of Chapter) (coma:encin&
with Section7000)ef IS vision Jof the tlu,inns add Towle ions Cove, and my Iicewe
Hane-'a tbn farce once c et
UClaQ F =3� Lie. «, JAS G T-
D:vc
-
REROOF -
—/— � -L— S u�• /H
e DECLARATION ,
Ao, he
1 undvotand my plan. shall he used ax public :csysnls
hall u pubb,
Licensed Profeavonal
OWNER - BUILDER DECLARATION
I hereby allirm.lhat I am exempt from .the Cond:emrs I.icense Law Bona,
'
following reclon. (Section 703 15. business and Pmfesxions Cute: Any city' or county
which mobiles a permit td comma, she,, improve, den boll. or repair any structure
'
prior ms is issuance also requires the applicant for such permit m file acigncdaacmem
S Ft. Floor Area
q'
_
Valuation
that he is licensed punuam to the provision, of the Cnntmenrc License Law IChamer 9
(cmlanmleing Section 7000)dl'Division
with 7 of the Business and Prnfedore Crou)
o, that he is exempt therefrom and the basis lie the alleged exemption. Any violation
of Section 7071 5I,y cry.ppllatnn for a Permit .objects the applicant to u civil fenah y
of not more than fine hundred delta,,USyrd.
APN Number
Occupancy ype
01, a, owner of the propery, n, my employee, with wages as their wle cnmlw•nsation,
will do the xerk, and the ,uuanm f, nut intended m olfemJ for sale (Sna. 7044,
y jqulred Inspections
Business and I'mfessiom CMc: The Commaor', License Law doe, not apply to as
w r of pnslmny Who huild, or ingsrovu, thereon, and who does such walk himself
_
or through his awn employees. provided that such improvements ate not intended or
fie If,
305 — FRAME
oaered owe. rw ever: the buud:ng )r'ttm,owetneot is sold Milan doe yea, of
completion, the owner - milder will have the burden of proving that he did not build ry
307 — INSULATION
oopr„vef..parm"cofx;nd).
❑ I, a, ow a', of the propen y.nmexdoaEel,c�ntroctin, .In liicenscdc...... on RS
601 — ROOF TEAR OFF
Lsoma the project (See. 7044, Business and Prnfes000s Cook:) Contrac or's
icense Law dues not apply to :m owner of pmpeny who builds or improves thereon,
- 602 — ROOF PLYWOOD NAIL
and who contract, for such projects x;th a commcmns) hceawd pursuant to the
cmurter", Lfcerw Law.
603 — ROOF BATTENS .
0l toll exempt under Sec. .B&PC for this roown
6041— ROOF IN— PROGRESS
Owncr owe
.
WORKER'S COMPENSATION DECLARATION
Ihemby sfnmt under penalty of perjury one of the following declarations:
1 have and will Consent to se for Worker
a Cey Seel
npanmdon, provided a
provided far n4, Section 77(X1 0l' the Labor Cole. ❑x the
Labor he
e
perfonna:tce of the work for which this permit is loaned.
01 have will maintain worker required by Stains
l
_
eCoators,
the
he of the
[ is work l t
1'e, which the permit is
for the pcnseance
issueof
issued, My orker Conn
C'nmpr:nvtion Insurance tamer and Policy
a d Pro are:
//tub��ker',
//number
Caricr:_ (L(a � is
C �GNKERS'
XEIAIITION FRO
COMPENSATION INSURANCE
r1his section need net rte mmplemd if the permit is for one hvmme l delldn
(SIM) nr ),I
/
certify that in the perfnrmmcce of the work nor whib tat, peon, is issued, I
Q
/
shall ndt employ any person in any manner so a, to become subject to he Worker:
compen,mion Law, of California. Doe
•.
Applicant
.
NOTICE T(I APPLICANT: If, after rr.Aing this Ccnifleam of Eacmprch you mould
,,wine subject td the Worker's Compensation provisions of the Labor Cale, you most
forthwith comply with such provision, or this Ismail shall be weaned revoked.
.
CONS'1'RUCUON LENDING AGENCY
I hereby allnn dint mere is a cotutrnedon leading agency for the pMom,ance
_
at he work for which this permit is issued (Sec. 7097, Co, C.)
Lander', Nome
-
L.endeC,Address
I cenify thin 1 have re:ul this application and stale that the a',, information is
correct. 1 agree to comply ,ill :JI city and oarmy nrdinanccs and state laws mainly
In holding construction, add hereby authorisesePmscrtatives of this city to enter upon
-
lie .bnvc- mentioned property ho moron ion purposes,.
(We) agree to are, indemnify and keep hnrnlms the city of Cuperine again
rtmil lic, judgments, ants and expenses which tray in any way active against and
City in claesept,tre rl the grunting of this permit.
'
APPLICANT UND STA 'DS AND WI COMPLY WITH A.L NONsOUST
souRC dECU 1• 'l
Issued by: Date
7 am/
sig�ate.c ofnpPl m"
o Y)aa I,
Re -roofs '
HAZARD US MATERIALS DISCLOSURE
,
Will the applicant n, In Nor IJing reculvnt store mhandle nar.Wnm numdal
Type of Roof
YI -
s
a. dewed h� me capendo M1l iPal cede. cnapmr ),IZ, and rte Hc:dtn ann s:dxty
Cafe..Suetioa 25572(.) ". -
0Yax No
All roofs shall be inspected prior to any roofing material being installed.
N9d the aPPEnaaronal hall ellacd by he BayAe. AnrChain, Management i when
mil bnVill the ter applicant r f , daOncJ by the Btu Ara Alf Quality Makes h
'
If.a roof is installed without first obtaining an inspection, I agree to remove
p
District
❑Ye, Nn
all new materials for PP
inspection. Applicant understands and will comply with
P
all non -point source regulations.
materials under r 6.)5 nl the
1 have rem( the ety
- -
Casous
25505, 15533 ?5574.
4.1 understand that
Cttde.Sealedma,
iftheomiaHeahh,on"l th25577yr
if Ihnbuilding Ares ant currently have utearoom that it is illyssuanmibf mnfican the
otiF
occupant of the requirements which must M met prior m issuance of a Certificate of
a
'
oeananey -
`
Signature of Applicant Date
ow "er rase...... ags ,a
All roof coverings to be Class, B" or better
OFFICE