00020114 r
CITY.BUILDING curESIO Na PERMIT CONTRACTOR INFOR A ION- PERMIT rvo.'
BUILDING DIVISION +�+;
BUILDING�A�DDjR�ESS:
SANITARY NO. APPLICATION SUBMITTAL DATE
FER' NAME:-:A1 ",J; bra CONTROL
#
I. lvN /59(0-5300
ARCHITECT/ENGINEER 1 Iq'n FCRMYT tNpO
°'N,°= SitlC Astec a.
4.,16 a.� . ;. . : , .. .,� ... ` •�-; - •:
LICENSED CONTRACTORS DECLARATION 4
O Z ❑ I thereby affirm that I anto licensed under provisions of Chapter 9(comma s ; ` Job Desenption
S z�w with Sam nT000)ofD - 3of drc Bui aatM Profeuron Code arM Ylim se � .. -/yy �+ (� ,,a �"'�(� ,.
$d a •in full f ulA effect _ •• - ^•��V y } 4 tc7'A I d\,olt I c(Q�
iPj3 O°w'U' Lim Chss " Conti `Du r.'� C.J `.1
3 LL F DeR Contractor
' !
a O a ` ARCHITECT'S DECLARATION
j,-r '• (understand my plans said be used in public records • .� '� ,i.. t� - t
d 6�
dt ❑e
Devised professional _ r s
'OWNER-BUBAER DECLARATIONs - ,
f^6 a f hereby u(Sect
G 1 renexempt f Ne Contractor's L crnu Law far the
following no (Section 5,Business soul Prof noa Code An,city coreout,
whq 'Ra.Pnitmemeat n mature re
h ...
c.
Sq. Ft Floor Area +valuation
prl rl 1 s6Uan also RQY1R3 Nefppll Hoff BCh pelrNlmfleaR gnEd alalErlle111 - �' ,O� y
Net he to bcenred pursuant to the provisions of Ne Connecmta Wcenu Law(Chipre 9
(commcncrngwiN seen 70007 fD' non3of Ne Bunnesa and Pr fess cox) r A ane
Occu e,,
hurt hes exempt theref d dMie basis for Ne alleged exemption.Any -olad N Number,.
of . < P Y TYP
`Section 703 1.5 by any appl'mnt for.parmu subjects the eppl t is a c ml penilty or .r,. - • "
nm moa Nen Ove hatMRd dollars($500) _J Y
❑Las"owner of thepropeny rmyemploymwthwagesutheheolec penaae n r. !Required InSpe
will do thewmk,mdde tinct rc isnot insendedoroffered tonal (Sec 7044 Bursinears,
and Profesnone Cox Th Co ira r License V doaIron apply to an owner f
properly ho buddy at improves themethemenn,and who does such work himself or through
her own employees,Provided din h1rnprmcmcidr m not intended or offered for
sale If h thebold' g mprovem ti-s Idwomnn neyearofcomplEdo No- 1 j
.owneobo Ix ill haw the burden of proving Neth did n t build ur impromefor P
fiat
9,u owner of Ne property am exclu.vely conu...st with,1 recd conesctots to "'. /
emu I Ne Project(Sec 7004,Durant.and Professions Cade:)The Coneacnof6 U. ),ty
cense law does n pply tom owner of progeny who builds r impi0ves dues u aual
who connote prolmu with a commetor(a)licensed lamoent ro the Contractors, v }.' •A, sa', ^.J
License
0,
em zea S B&P f ithl '
!• Owne "Dao r a I' ,
W0 UI S COMPENSATION DECIL R TION _ ..
1 h by ffirm under pcvltY of pepury one o(Ne follow e d luasiovs s y, .,
❑Ih and will meninwn.CemficateofConsenl to sel6ma fo workeis Compeer
e� tsar, as Phi c this
hi Ire i Swoon 3'!00 of Ne Labor Code,f Ne pertomunm f th .o , _ i
workfor and Neat 1 Iced - a 1,
II `37 I have end will ed nein me eke Comp ofth Irk for which
es speed by Sect c
`3700ef rhe Labor Cod f N p<rt fih work for ah tide permnra is ed t yD
f My Woxete Compcn6af nlnsurmce cameroli Poliry numbs aR.
CERTIFICATE OF EXEMPTION FROM WORKERS
t COMPENSATIONINSURANCE t t
(7th' sap neMnm bac mPlemtl fNepetmil ,f tone M1urdeeddoll (5100) " T• d ,
or ices)
Icemty Britain the pert annex nas kf hichNs permokers'Ct is .I ball
1 notLam on'nm manner Son to become sub ecr to Ne Werken'Co
' -1 no YPe Y 1 Pen-' e • ,
r.
�•
action Laws of California,Due ,_ .• s,. '. )f ,_• i¢' ,. - '• '
Applicant- - Ir ' a1
NOTICE TO APPLICANG IT'aflcr making this Cemficare of Exemption.m you should'
become subject to the Worker s Compensationproislons of the Either Coee,you men
fenh iN comply wide such provluona or da6 pe 1 shall be darrcd revoked.
+'•z , CONSTRUCTION LENDING AGENCY •+j a' ,
..O O Ihereby ufflrmNallbmc. a pdiwcu lendingagencyf theperfmmmc of. o ; •m r,t " ?
ti `Ne work for which Nta petmn n+su (Sit 3099 Co,C) t • -
.Fy Lenxr3 Name - 9
I<iWer s Addms� - - ^ -
W Q 1 unify Net I hive rite p @"me pia that the boinformation's t ,
building
1 egrse se comply core I cit c ty ordmmcn d cul laws recti t o n +
• r1 Z buildingcontotemn and M1ombyaurhonurposes. fives ofthis itymenrer sego-N
'U O •
above-mentioned ProKnY for inspection Ourporre
W F (W)agree N vvc,indemnify and kmPmay theory
a the Cum to part - ga ret .. � � , s» 1
O V-,li.h 1 nes Ludg rnu,emu end expenses
which may n any way amme against said City
�., W m con. 9ve of the granting of Nn permit . +. �S(=g
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT F ,
;SOURCE REGULATIONS
Silaborcut Applicant/Contrnter' \ - Dale Qea /—//VxcTV ucc 4. -
' HAZARDOUS,MATERIALS DISCLOSURE ' i
Will Ne`applicmtorfinurcbuildingeccupantnmemicirclehaosedoo,maorial Re-roof$ -p -
as defined by the Caper o Municipal Cod Chapters 12,me theHealth and Safety Type of Roof '
Code,Sar m 25532(.).
❑Yea _ 1 _, \ a .
All roofs shall be inspected,prior to an roofing materlal'being
Will de aDPlrcmt r fuwre building cupanLuee e9u pore n r xvl es th ch yy
EmrhauNo amm�� t, definW bYNeB.yArcaAeQ tltyMmagement r installed:If a roof is installed without-first obtaining an inspection.'
°`tec,? I aggrbe-to remove all new materials for insped'tion Applicant'
understands and will'comply wifh,all non point source regulations.
"e'
s materials resulRments under Chapter 6.95 of the Cat „ -
Tum th efcly Code,Semens 255(15 25533 nIM 25534 I and Imd thin f the s S -
buil 'gd t line Oy hav re nt Nn'rlmY rcapomt tyN ufy the mcupmt
of rc9 hot t 1 iyat tee_of a yyypsSc fqc upggr�� `
' .n � SLgna[ureofApphcant 'Date • '
Ow Iho'zed.,cut -Dam I - - .x '••
u
..• - � - � �All roof coverings to be Class"B"or better
OFFICE