000501271.1I I "r uUrnmi IINV
BUILDING DIVISION - PERMIT +
BUILDINGADDRESS:
lu00
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aZw
n LICENSED z O H = 1 hereby am ffnlimit sem licensed r 1 euxnsed under Provisions of N
Chapter 9 (cammercing
O m w wish Section7000 of Dtvisign 3 clubs Business ao R&f.aiom Cade. and my license is
~ y i In NII force --u 15 i
0 Idcame Claes Uc. #
a V. I.. one Contractor
C O ARCH CI'S a puM ic�`
S LL r 1 mdemnst my priors shall thee, Uses u publ
w i ° O Limned Professoriat
n
n=, OWNER -BUILDER DECIAAAnON
1- z < I hereby affum that 1 sus exempt from Ne Contract&. Licrose law for Ne
i — e following mama: (Salim 7031.5, Business ad Profession, Coda: Any city a money
m which requires a Permit m consumer, after, impmVs, demolish, or retain my smrctum
Poor to its Issoarce, also requires the applicant forsuch pemtit in file asigned statement
that he is licensed pursuant to th, provisions of she Contractors Licmu Law (Chapter 9
(commencing on Smdnn ]000) of Dwiden 3 of she Businae rust Prof.Wom Code) or
thin he is exempt therefrom and the basis for the staged exemption: Any vichOcn bf
Section 70313 by any applicant for a pcmtit subjects the applicant 10 a Civil pevlty Of
nm more Nen ave to rdred annus ($500)
1, as owner of she propeny, or my employee. with will. as Renault, compe.adon,
will do the work, nM Ne structure is not intended reoffered for We (Sm. 7014, Basi..
W Professm a Code: The Connector's License law cora rw apply 1. an owner a
propcny wo builds w impmer. thrmn, and who dons such work himself or through
his own employees, provided that such improve vinta are am intaeed in offered for
sole. If ioweser, the building or improVemrnt u cold within One yeat of mmpluim, the
owner -Wilder will have the Wooden of proving that he, did not build m improve for Par -
me ofGle.). '
` ❑ 1, as inimer of she none", am exclusively contracting with licensed contractors to
conswa Ne raja., (Sec. 7W, B.,ars, and Profession, Code;) The, Contractors Li -
Oman law don. not apply to an owner of property who build, or ima&V. thereon, and
who contracts for such projects with is mnuacmt(O licensed purtuem m the Commerce,
Licrose laws
❑ 1 stn exempt w rum Sm. . B A P C for this re.nn
Owner Date
WORKER'S COMPENSATION DECIAN,k-noN
1 hertbY affirm under perW ry of p[Ijny oa of Ne following dolantiom:
1 Nve are win maintain aceniacam of cont m alf-inrom fm workers Compen-
a as icprovided for by Saxon 3700 of Ne Labor Cady, e, for the perfernin of No
Awol
rkforwhichChiapermitisi.ued.'.
1 have 'and will maintain Workers Communities Imurmce. a, mound by Salion.
My Wo¢erfa[prggyy'jtjpp baYllltce Gamier entl Policy ny�her aFr'ia / ] �•
(This statim teed era bu rnmpleud Bshe pcmtit in Teruo huriAd ddlan (5100)
o leu.l
1 mnioy hawin she anymues, ofted workfmwileh Nis peanutisissad,lshsl
notemploy of person in any manner ono ntobmwrc wbjono dm Wahan'Coman-
Appli laws of Csifomia. Data
NOTICE
m,
NOTICE l'O APPLICANT: If, isfixori testing this Chimes of of Exemption, yae should
bmome m amply tie Workers Coons in this
Permit
steal of Ne Labor Coe, you muss
f&Mwiih comply with such provisions or this permit nhdl be drama revoked.
CONSTRUCTION LENDING AGENCY
I hereby aRmi that thane iso construction l,nding agnrcy fa the perf.ca.f
z Ne work for which Otis permit is issued (Sm. 3097, Civ. C.)
Ew lenders Name
Landers Address
W Q I caniry that I have red shin ,[least. and some than may aW a information is
contract. I agree to comply with all city ad e.my ordurnm e, and sum laws relying m
a7 z building construction, and hereby aushorice repreaenimives of this city to enter upon tie
U 0 aova-mentioned Mean, for inspection putposea.
W I Fw (We) agra to save, indemnify and kap hamiles, the City of C., ening against
U llabiliti.,judgments, Corm and expenses which may in any way accrue against said City
�y W in consequence of the granting of this permit.
•r Qs APPLICANT UNDERSTANDS AND WILL COMPLY WITH A I.I. NOMPOINT
U z _ SOURCE REGULATIONS.
AaL4A,Tri--'pUAp-e
P•� • f'�- 237
Sew x� � -gsrs3 .
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t.lt.jt'IU HN��
P�'litrN!J St�Q
A02-PAi a „tl•r. r.
Job Description f
oy. ra. rwvl nI ca
3 s ed ir�r- ffi l�
4 1 /
Signature of Applicand onuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will No applicant orfurufc Wilding mcuyen, store or handle hazardous material Re -roofs
as def and by the Catoctin. Mani,,,l Code, Chapter 9.11, and the HW N and Safely
Cede, Section 25531007 -Type of Roof;
❑Y. No
Will the awlicmt or future Wilding minimal use itipme.,erdevices which All roofs shall be inspected- prior to any roofing material being
mit Iniad&usab<onuminmm is, de6nnd by the Bay Arca Ab Qedity Manapcomet installed. If a roof is Installed without first obtaining an inspection
"r7
❑Ya ❑No I a ree to remove all new materials for inspection. Applicant
ti
Ihave dNoha>,slim,materw,mgaircmm,.mee,L,mpms695ofthaCall- understands and will comply•with all non poinf source regulations.
formic Health S, Safety Code, Satimm 25505, 25533 and 25534. 1 usterstast that if the
buildingdo. notcurrenOy haveeoewnt.Nati, is mY rtapomibilirymmtifY ohs mcupmt - '
of dm rcquuemenm which
Owner ar authormon be ten prion ro isauena of s Ccniacam of Occupmry.
Signature of Applicant Date,
•'ised agent D'am
All roof coverings to be Class "B" or better .
OFFICE
PERMIT NO,
SANITARY NO.
APPL ATIONSUB
NIC
CONTROL#
HUEND INs iI;RMITiNro
Job Description f
oy. ra. rwvl nI ca
3 s ed ir�r- ffi l�
4 1 /
Signature of Applicand onuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will No applicant orfurufc Wilding mcuyen, store or handle hazardous material Re -roofs
as def and by the Catoctin. Mani,,,l Code, Chapter 9.11, and the HW N and Safely
Cede, Section 25531007 -Type of Roof;
❑Y. No
Will the awlicmt or future Wilding minimal use itipme.,erdevices which All roofs shall be inspected- prior to any roofing material being
mit Iniad&usab<onuminmm is, de6nnd by the Bay Arca Ab Qedity Manapcomet installed. If a roof is Installed without first obtaining an inspection
"r7
❑Ya ❑No I a ree to remove all new materials for inspection. Applicant
ti
Ihave dNoha>,slim,materw,mgaircmm,.mee,L,mpms695ofthaCall- understands and will comply•with all non poinf source regulations.
formic Health S, Safety Code, Satimm 25505, 25533 and 25534. 1 usterstast that if the
buildingdo. notcurrenOy haveeoewnt.Nati, is mY rtapomibilirymmtifY ohs mcupmt - '
of dm rcquuemenm which
Owner ar authormon be ten prion ro isauena of s Ccniacam of Occupmry.
Signature of Applicant Date,
•'ised agent D'am
All roof coverings to be Class "B" or better .
OFFICE