01030157 CITY OF CUPF,RTINO
q = ?Kin.DING DIVISION • PERMIT 'CONTRACTOR INFORMATION `
e �
BUILDING ADDRESS: - PERMITNO.
22065 CLEARWOOD CT '_ '
OWNER'S NAME: i - APPLICATION SUB DATE '
REBS' KATHRYN S -
30NE: - S SANITARY NO.' r .CONTROL NO:
ARCHI'1'ECHENGINGER: r .•J BUILDING PERMITINFO
O O - BLDGELECT 'PLUMB-. MECH.;
- L_J L -` t_
G U�
LICENSED CONTRACTOR'S IN CI ARATION - '1.-- Joh'
D'
5 y& - Job Descri tion
O Z_� I hecny vll'na that l am l"of'od de.p fcl pt 9( ng I p -
F �W wihS n 7000).1 Dim,iona J the latsintainandP f ' Code,and ily�Icrnse
sttI111 e d fife t.
cr Class a--/ MASTER BATHROOM. REPAIR.'•
3 a r Due - ,
ce
ARCHITECTS DECLARATION
t� 1 haradrociandia,pl' .shallbeured , ablic'winrds - I �INALE-D .
Mfoo Licensed Pror Fanw - - -
°•n' - OWNER-BUILDER DI R ULCI ARATION
1 brehyadfirral that 1 ann firran,the Contractor's
Law I the
fall . S.......'91315 Bu.' JP Bossier, e Any ty , _
�AI
which hernias n e a alterp a fih,opy, t
20w
dprat t '. ceil. y Iliapplicantf hp tau fl fl ib J.tatc m
Y L
that liveried dp : II to p . nI Contractor.,I L Tro,Client,
' ' CI p 9 Sq. Ft. Floor Areauation(en s 'n Section 7000) Division3 r ho tr . 1 P f:: Chile) B�ILDINY
or l I . e npl th f th n lot to alleged e pt Any v off an "
,
of Sectioti7O3l.5byzLiiyappltft)i,❑I ' r , p 't: bl tp.tKoaplr a val.p EY
the P P Y Y pl Y ill, ng '. hg -�-. •,
_yO.
ccu-
pncp-
enfnt than fvehardballarl,t(5500) APNNumber'
pe. an.
vi e d k a t t . tintended rr d t l (see m44
Bus a Fiat ,,c dur Coal t t: La d t( l t t Required fnspections
ow fp pnyWn n n. p d u d e l . n kn . ll
rE gunprp eddtuh ra t: w t ted
offered Ior ale If,however,the bur mprsola w thn year o 516 -.FINAL -BUILDING
�oh,lainn,thenwner-huilAer will ....ihe harder,ofpnviag that he did a.,builA or
tp
Ina
❑1,a,oonaroftla,property, ly coarrinaing withh ctW that
,irs to
construct th project(S 9144 Bit and Professions C(xle:) the C 1 hors
'Licerfe Law d :han acid,teen twarrof pofiafy ha,hard, int,two,rancor.
and who l!obereacts for en projects wish11 ,nmetor(s)licensed pt dui ,w the
Cnntra,en,I.icen,e Lw.
❑I um exempt under Sec. ,It&P C for thl..Aisnn f
Owner 'f�• Dae
WORKHR'S COMPENSATION DECLARATION - -
1herebynlGnnunde,penal,of perjury one tithe fiolowin%Jcelunitinne: ,-
)'1 hove and will mnimain in Camille., A Convent to'elf-instne for Wdrkcr's
Cominnsution, as provided for by Sea n 390E of the Later Code fair the - -
parrarravoofineworkforwhine mis pd,nit it i,sued. ;t, • ,
. a 4
ry +11rive an d II n W k C p i : y byS Ton _
3111[1 of ter I unnr Ctdr fin Ibe perfa n of ter work far which this win...is -
issu d My Workers Con,Nnottion Insuidnecerfriciand Pal'cy'numrbycr erre,
•Carver 4z bi e , :' Vol'ryNo.. to C_
CER IFICATION,OF EXEM1930N FROM WORKERS' d _COMPENSATION INSURANCE
(Thi,,velinn need ant be ran,Baal if the naarh i,far Ona handled dolmas
isldin or lest.) - _ -
Iceaiythut adhe ponfichronan,ofthwork fri which thparnit'. '.rum,I ' t
sI, no, inflow any pe-. ,in any banner t as to writhe sahj,,l ,,the Work,,'
"'a
trt Laws or Cnl'forna Date I1 •}
Applicant
NOTICE TO APPLICANT IT after makty this CentiFicate of Excinpird,you ihould
hectm :bjai,to theta k Crat,ir,anchp v.' flea Labor Codcyoa bad -
0
forthwith omply with. 1,1 snmorth' perm vhall be dcened revoked , -
•�
CON STRUC`I ION LENDING NDI NC AGI
5 aQi Q
1 beral,aff i
' tl ttileading'aear
y fur rho prrlomuncc
of k f which this penn t Slashed(So,.3092 Co,C) s,,Lead :Saint,
Ni e ,
a Lenders AJArcev ad .
V I ' tfy that I have readth'.ap,la C 1.11 d tth h 'nl nit 4 •
W Ey a t 1'6 1 ply hi 11 nyanal tYcralinarce,too ande law,hilan6.
V tobtdd'ngnnstmcie II n1yu,Nor' epre'enlit've,ollhedtjtnencr pot. ♦ -
ryI the b n ,ed p i t p t p p!ev: -
,.F Iy Ol )'g i ' 1 'fy IA Iv 1 the City fCipriano.,ain't .. ,
ti.h liabilities,) dy l t d p h' 1 nay t any Y ...o again,( and ` Y
U.Z' City i a' 1 I the g r g nhi pc n t. ) . -
�"� APPI ICANrUN RSTANDSANDWILL COMPLYWITH ALL��iiN-P�fIINT � O J v Date ,•, /
So
C,l,,g/o 1 Issued by �-CL
signature f Appl' IC t t - - ` O",aRe-roots J
H ZARDOUS MATERIALS S DISCLOSUR t r Id a,
Will the applicant Final bud r tg ..p. t, ar 1,idle la„mous material Type of Roof
av deBnrd by the Conciliar Municipal cipal Core Chapter):12,and the Health and Sale(,.Seen..25532(a)?
E3 Yet,
r. All roofs shall be inspected prior'to any roofing material'being installed. -
W11I If a roof is installed without first obtaining an-inspection, I agree to remove
:mitl r I nau n', nsis defined by tireBay Area Air Quality Management ..
z
ester I. all new materials for inspection. Applicant.understands and will comply with
°Y all non=point souece regulations. -
- I I mJ the ha -1 3mr'I: 1 eme trader Ch pt -fi.95 of Ilii
Calif H It &SaftyCel S f :2550525533 and 255341 d .pod
that -
iftheb 'Idnydoesnot n'enilyhave:ten t,tl t it'tnyrespns'bilitymnnl(y the
reaper t,f the retry • t:which inteth my prnr to hot I if life f '- - ” +. ' • _
t Occupu ley + - 1
SignatureofApph'cant +- Date
ownor or aatilTh�gent 'amu, .' All roof coverings to be'Class"B" or better
dr:: 0FFICE ."y- * s.