00060180 clHmoFcoPvRrNNo - CONTRACTOR INFORMATION:
PERMIT OO.O �v O $ (O
OUILDINC DDRES
! 6PERMITNO, -
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OWNER'S NAME: '' APPLICATION SUtl DATE
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r'HO : - - - SANITARY NO, - CON'BOL NO.
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(9r_,O O ARCHITECDENGINEER; 1, - - BUILDING PERMIT INFO
<�'u❑ „�, BLDG r:LECr PLUMB MECH
LICENSED CONTRACTOR'S CI ARA9ION
? Job Description
ZORI lic,ch,unpin,. Thin It J n l' 1in,Cod-9(e,mli g
CW ;itnflllf ]IIW)e�I) " 1,I the Bo I1 r.esasC,Ja,and nyliwmv • I - •- •� _
re'x�a Lir a.=an -.tt3� . Ica 07S2L2.16o
x O U Data-F a 1 ry
Cnmam -
III 5 u fin ARCHITLCr's DECI ARAIIO _ -
yyy��� ,g I r W ny plans.h.Jl he used :PUMc records Lry
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OWNLR-RUILDFR DI CLARATION
hereby.flan In.'I a n.scams from,he Comas r:lasaava Law far toe
following reason.(Section 7011.5.Business and Pmfessiuns Code:Any city or county
which requires a p.it 1.construct,alter imp nwq demolish,or repair any swcmrc
i3Po priorto its issuance,also requires the applicant fmsuch permit to file a.signed statement .
mat he is live llsedpurmarra nae prtwlannof he Conmoewe,License Lane(Chapte,9 S .Ft. Floor Area Valuatione(eomncneing cal n :m
,Seenan]nanalvision3m'the Btlameand l'
.. ml'cs'ions Code) y'
,r Thal he is cxen,pt thetnfroin and the basis for the illegal ascription,Any violatinn - -of Section]031.5 by any applicant for a penin subjects The applicant m u civil penalty '
of not more than five hundred dolmR ISSUE). AITN Number. Occupancy Type
111..1 owner of'he portfamy.ol my carI Is FIE a g. .,ha�r-.larmahemiumm.
will lo'mc orl, d h l are is not mcniled'or offered Fit:I (Sec 70
Ba ailI I r,- n Care'. fin c t t "I 1. Lir1 : t pply'.an Required Inspections
w e f finite,1,Who Inalthor it... themor.mad h dra,soult - k himself -
or
thoard,his t wn ampl yew.pr aided(bar such memormart,ap.'nol mended ,r
offered far sale.If,however,the b,i chm,or improvemcm'is sold within one year of -
completion,the owner-builder will harm the burden of proving that he did oat build or •�
improve far purpose of sale.).
El 1. r,h p pe,y aclu. lye t t b m 'licensed nomct
mt Itl 1j T(S 7044,8 Jt1 :CI ) ILC tilt '
con
Luw does not apply to an 6wear at property 1 hadds try toprovesThereon, -
and his m ., far such p at'iwith et
amaarlsl licamed p , m
ant
Comm �
O
Contractor'License lA `
.O I am exempt under Sec. - - ,B S PC for this reason
Owner - - Date I ^
WORKER'ti COMPENSATION DECLARATION
1 hereby affirm under p.nahy of Perjury one ollhe following dada stinns, '" r
M1ave and will named. u Ccnifcam of Consent m Ulf-inure far Worker'. ..
Campenation, as provided for by Section 37NI of the Labor Code, for the
perfnm,ancc of the work for whicM1 thi>menni,is issncJ. '
❑I have and will nmintain W..I,,r Cnmpcaa,; Inxurancc,ns rati;aal by Section . .
3700 of de].shot Code,I'm the performance or The work for which tots permit I' -
sued.My Worker's Compensalion Insoiance carrier and Policy number orep: /
.. •Carrier. C rV A Polley No,:W NA-Z?y 497 1 -
CERTIFICATION OPIIEMPI'(ON FROM WORKERS'
COMPENSATION INSURANCE
(I r,'actiI need nor he ion,latal ifdiI,penult is fvronc hunJmd dollars
(8100)or I"s.) '
1 amity,hat in he ped mmorme of the work for which this mennit is issued.I
shall no,employ any person in any manner so is,In become subject it,the Workers -
Compensation Lax,of Cadmania.Data '
Applicant .'
NOTICETOAPPLICAN'I:11,uficnnnkin�this Cenificure of Esemptit yoa'lould
become subject to thb Worker,Compen.dmn pnvis, n nor thn Labor Code,you mat
z 0 fanhwith comply aim such pmvixians or this permit hall be,deemed revoked. -
z2 'CONSTRUCTION LENDING AGENCY
ai1 hereby affirm That there is a contraction lending agency for he performance,,
erformance ,
W of the work fur which his permit is issued(Sea 3097,Clv.C.) .• -
��11i Larder's N ase
Uz Lend :Address
Q 1 cavity that l have and this application I state that he above if ,
t..
correct.I g t comply with oil ry Ni ince and:,to 1 refining
g
0 representatives
V m,building t do hereby
and rry,h nt f add city, l , upon • ✓ �.l V
[i] he above-martioned proI for i mrsationpurproses. '/y/y/J/,
j. a (Nal6 t dtnify dkeep l :toe City fCp foo against
I t•
W obi lit,,. jmIgnatim,costs art asle . . hill'"all any way acgo'11�t said
V z
City in ugmvrI of the staining ofili perml.
�.
SOUAPP
UN ERSTANDS AND WILL COMPLY WITH ALL NON.POINT ITIONS, ssued by: D:IIe s•-/ 4 V O
ignature orAppficrnvcommim Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE -
Will n,a aPPheam or mobs brining a..spam lnm ar handle nu.,,lrlmc,ouveriA Tl pe of Roof
as derimd by the Cnpenino Manidpal Cade,Chapter 9.12,and the Health and Safety -
Code,Section 25532(.)9 • -
❑Ya' ON. _ All roofs shall be inspected prior to any rooting material being installed. a
Will the applicant or fumfe b,ulding wcupatn use equipment or devices wNr ch If a roof is installed without first obtaining an inspection, I agree to remove
'mi,hazardous air conmminants as defined the Bay Area Air Quality Management p g
itanct^ • ' all new materials for inspection. Applicant understands and will comply with
°ye,
°Nt all non--point source regulations. • ' '
Ihate reel tntformation,pmaterials
'.q ' 'ca d Ch1, 695mf he
California Health B Safety Cod Sections5505 25531 ad 5514 understand that
ifthe bWJasnm rthave tenant,
en thatri i. y pn blay to nmir5 the
occupant of the requirements which mot h mel prior issuance f n Certificate of
r 3- .sV•(„�+S � n1`/v/
,-
I` Q ✓
OccuancY.
Signature of ApplicantDpte
A '
" Owner ormol artied agen,. Date - -All roof coverings to be Class "B"or better _
OFFICE - -