00080036C' BUOF GUVSIONO
CONTRACTOR INFORMATION:
ILLDINDIISINPERMIT
I3UIhDIKG A µlySS: 1
r..c)IkIFSore•r is Y.:> fr u:a �Ls
3f•:,
OWNER'S NI l:hlr)FI .�Ahlr.)W.l.rl:
�tiJ �I!) FIFE W�:)OD 1..•r.
)p)n}UIc:)r}rAc)r.)
APPIJGf10O(:)f
lN!(11.
SANI'I'AI CONTROL NO.
�IIONE.
(408) 927-0560
AItCHl1'ECIILNCINEER
BUILDING PHR1,11'I' INFO
_
BLDG ELECT I'LUMR MI?GH
rlDltL77r3;ci°�
Job Description '
t I a�todel >1 nlnle,..,g
r.�.�ciC 1 In'li,ore
Insl�roe[Itd's,
a 'n
n:r.F; Caahlr�r.r:r.lahl nr�r>rr:r.lall
lh 11 ft cc ut Hlfe
lai," Cuw 0 u,.%_
c0tt'
D.ne m.o enmrhea,t Nm,r =
DLCLAI ,ION
ARCII'd
be to
j hmdenamti n,y plans sl,nlf he arc+ :w pudic rccurA.s
j Licensed Profceslonal
OWNER -BUILDER DLCLARA'rION
I hcrehy if int Ilial I ait exempt smote the Cnnunemi's Liccme Law for or,
fall b (Securn (Sect7011.5, Busincll ood Pilobessails Cobi CobAlly eily it c u ly
1 ,ii,11 eitair, It rerrit to Landst' t, i int'iI'.1 I' 1. tuamm
pr'c tire al... ro e, the: pptE an tor st it per 'Lot lo Ile a yb Od slatenoton
Sq. Ft. Floor Area
V y
£♦�4CiC)
nn_ (()
lit '. licensedvan II 1 ini I' C I Chapter
(c, k will, SeU 7L l I'M 3 I Bine II f.:'r ar Cn a)
,'Ilial Le is exnrpt thumfmm and he M,as Ort the illr,e,l d,,,nn, n. Any vinll,
n1 Sector 90.115 by try aliplleonf fnr o perm'u sadncets Ili, appl'mtuo lou ,,it wrally
of nol more lmw five not daaara(551'0),
Al yrynb r
Occupancy Type
❑ I. as owner of the PO.'I or n,y "111to ws with wager as Boirenle comprnsofon,
will do the k and bill ILILI'lIs t Intended 01-ifloold Itir saic(Sec. 7044,
on i l r r as C 'I c t t. I l _ Lad pt I> It an
q� t�I[1� lens
Il 1pivWhllhtdsrr'nprl n
th'i'l,, ,it odo-a-hwarkl ,df
f
.i3I%):1. -- R )UCI-1- lfl� . .jl
Ir1pravcams a not intended (it
,r Ihnnagh his own unoployeew. provided that sold(or
ItI�UIJF'l l•Ii_L.1"16Ih1:1.tvAl_.
aNcvc
OrCOLI le. it, I'll thn m
e hadding prn cntis suld wlNin old yea of
nmpinl un, one -n-l000ILL will hwe the hutdan (,I pmvi ng than dd did nal hold m
,:;O,3
:i3t%1/i -- R0UI:2,1-1 El f::C'r'14I C: A l._
mpmxe for parpom of sale ).
...
. ....
J. — I-.L1`I6I1_ Ic.l_I::.(.. TI•i.I: :.-... ::.Ix ::. i:,
❑1,a.nwnd the ematnessiaisIli hewaredname,cyama,
..t(j
oed(Sioeny,atn�ew,!a ended'rha.Ibil fora
�,lerld lbepraieclrsec.7to!i O,rtr.1amtely
I:ii(2)i:> .... I'•:I:14f-IL_ f'L_l.11'Iri�1:14C) Ii_hIL.F{GY
I Low draLlsfron oyadywhn buildsot
monown diol
id
Who sort
and wbn cosines, air .ndla p freta with a cw,nawads) denied pn twm In ate
Onfli a loodAnslhto [Ile
t•_Pp7;:3 .._ I:; :1146.1. 1'11":CFi0l4a: C: FII... I:CIll 1:.:ROY
kt Lamnse 1_nw.
El I noW
❑lino exwapt ardrr5ec. .B&Pctrin,r reium,:,Irl;;,
._• 1::•1:146II_. E:'LECTRICAL
;waer Date:fair-II_
1:11...1.)rl:;:r.hlr)
WORKER '$ Co MP17NSATION DHCI.ARA'I'ION
'::5(2)1:1 1:11401_ I•IIM1•I0141CAI_
I hcrclay allirm undo penalty of perjury one of the fallowing dcelarnfmns:
I I have and will al,ibedr, a Ccdilicale of Conecm m nelf-Inrum Ili Worker's
,nhprmalion, as novlded for by section 3700 of the I,ahnr 6,M, or ilia
performance of the Work for which this pmmit is'mned-
❑ Idote and Will 1IWniker's Compensation Illsllnnmr, ;is rryuired by Section
371'() of ibc Labor Code, in lie perfunnancc or the work lin which Irie paten is
sued. N1y Worlmrs Ctmtpcmal ion Inrnnmce carrier and Policy number .,or
I, TZ Adowdrll'r 2� 6i
lino ruddy No. Y_5_
CERI'IIICAI ION OIL 1!YEMPTION FIE;k1 W(IdKERS'
COMPI?NSATION INSURANCE
r II, cairn nsdd not no emnptmal it he per tet„ fnr One[birdied dntwaa
(S 1001 fir tenet
Iiy that in tile bill 1 volaad elaAIOr whichbill pelinitis6wed,I
11lad t I Lilly 1 nt/�� I t,, l,zd ryll t I the Wt kcty'
L,
Cm l ul wa o(Cd�l� e_ _
Applicant Si 11..�1J
NO IC]' I LIAIFTLICAN'f: Il: adm making a Certldem,IOf 11EIloo, ytlll shoalft
aubjmtln ldt o 'he I`r
Colnpellswl01, pat nfedLabor Coda yot oust
fodhwhh c apply wills each Vn ,petro fir this Ver nu Jmll Fe deemed acvuked,
inch
CONSTRUCTION LI.NDINC AGENCY
I ILI ancon atm them is a mnsannlnn loading ngency ear tile pvfnnnuncn
nilhe wolk for whioL B,I, pmmit Is issn,d (Sri. 3097, civ. C.)
-,I Nwdc
Lcndor's Addrese
I cetary that I have read thin applieso 1 and nlil, tom the It infotmalien is
aeel.
rI a"', to m
dnply with unty alt edy and coad notices moldt, no
tl steLaws rcla,
m huildn" Land"I I and hcrehy arborize vVitsenoolies of dill oily to ether upon
the uhnve,n meioneJ propel y ter InsPcelinn propos
Ove) wi,e m lava inden.ddy and keop hill 1b, City of Ch.pedinn agoiro
le,hil... r , jadgmouta cosm mid cljol whldh cony in any way tenni, against said
City in conayueuer of the gmnling of III pet In,.
APPLICANREGULATIONS. UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issned by: Date
Sigrid,, of Appdcvn/C obaclar Date
Re -roofs
HAZARDOUS MAI F:EIAI.S DISCLOSURE
Will ire appllm I or Bowe [ Id ing n¢apam ,mrd fir Imadle ha.anmu.s nmtedol
Type of Roof
n dellood by aha C'upcn'mo Man'mipal Code, Chop dr9.12, and the Ilwhh and Seely
Cud, Smlou 25532oo?
11 yl Ed No
All roofs shall be inspected prior to any roofing material being installed.
Will trdappheartar minaemdlding occupaw n,c rydghmerl fir del firer whmr
If a roof is installed without first obtaining an inspection, I agree to remove
m'u baLurdoa9 oil nmte iliII as def red by the Bay Area Aar cloddy Mnnugen,ent
oiaaw:�
all new materials for inspection. Applicant understands and will comply
❑Ya` El NO
with
all non -point source regulations.
I hold read and Ihmardnn.s nmmriuls myaitemeuta finder Crt9arr, 695 of the
California liuullh k Safety Cade, Sections 25505, 0_5533 acrd 2553.1 I undersum I that
It fide building do, Of carmnEy Lave a truant. I ret it is by o -let (hilly,, ratify l ad
pI'll A Old bell Cmcno , led mast he met prier to isseanee of a Cl or
Sr ccitpancy.
�oa�rdoraedugem
Signature of Applicant Date
All be Class rB"
I>,e
roof coverings to or better
U"K;h