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CITYBU of cueESION
CONTRACTOR INFORMATION:
Bott.msc mvtswN PERMIT
BUILDING ADDRESS:
PERMIT NO.
20396 CLIFDEN WY
WATER HEATERS ONLY
02050041
OWNER'S NAME:
APPLICATION SU DATE
AMIRI IRAJ AND ZAHRA
970 E. MAIN ST, SUITE 2(005/07/2002
PHONE:
(415)566-2209
SANITARY NO. CONTROL NO.
ZO ARCHITEC`DENGINEER:
BUILDING PERMIT INFO
p
BLDG ELECT PLUMB MECH
i LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby official that 1 am licensed under provisions of Chapter 9 (commencing
of with section 7") of On izion3ofthe Business and Promxions Code, and mylicense
p
REPLACE WATER HEATER
is in full force and < 2
3G 33 7 V 7
sc Gla. Lic. a
O
Date e 7 Conwcmr
ARCHITECT' S DECLARA ON
I pndcrnantl my plans shall be used as public records
OLicensed Professional
OWNER -BUILDER DECLARATION
or I hereby affirm that I am exempt from the Contractor s Licenm Law for the
< following mason. (Satiom 70315. Business and Professions Code: Any city or county
$700
D which mqulms a mil m construct, aper, improve, demolish, or repair any structure
gi poo t t issuance.1. 9 the ( such perms fl signed statement
_ __ _ _ _
_
��V {'y 1,i:3�Yt66 V_v `'_/( }. i, 1�i xr
Valuation
— that h' licensed p ua tt the provisions -f theConmachos L La (Chapter 9
(commencing- 'thy t ]000) fD' 3 of the Business and PmfCcions Code)
or shut hes empt darefra n and the no,., for the alleged ei<mpion. Any violation
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of Section 7031.5 by any applicant for a permit subjects the applicant e a civil Penalty
'ofnotmom than five hundred dollars (5508).
50�PN�TkSL PLUMBING
ENE RG�ccupancyType
❑ Las owner ofthe property. or my employees with wages as their sole compensation,
— A TEST
- will do Ne work, and the structure is not intended or offered for sale Isec.'/BW,
Business and Professions Code: The Contractor's License Law does not apply to an
5 0 7 — FINAL P& 91'�ffij p ections
own f property Who builds improves thereon, tl h docs such work himself
or through h' empl y es Provided that chimprovements arc d tended or
-offered f le If however, theWilding -improvement' sold withinone year or
t the erh Id will have th burden of proving than h did not build or
e
imPo !o
improve for purpose fsale.).
O I f tb p pony cl 'velycomfort, lh licensed tr t ns to
_ /// __.. .. .
construct m project (S "IOW Business d P f Cady) The C vactor's
C
Lc La d t pplyt o rte ofproperty h Wilds or p th em
1 and whocontractsf such projects with a contraam(s) lensed pursu4m. to the
... .. __ . _ ......
- Contractors License law.
.... .
C I am exempt under Sec. , B & P C for this ..,an
s -
Own " Dom' "
_
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 hive and will maintain a Cmlficae of Consent to self -insure for Worker's
Compensation, as provided for by Section 3100 of the Labor Code, for the
Performance of Ne work for which this permit is issued.
❑ 1 have and will mutation Worker's Compensation Insurance, as required by Section
37tH) of the Labor Code. for the performance of the work for which this permit is
sued! My W'orker's Compensation Insurance carrier and Policy number we:
- carri<r,�i.a^.R-'i+mioy No �i/Gt•�i9�o/
:,:•- .__.. .. .. .
CERTIPICATION OF EXEMPTION FROM WORKERS'( -
r ? ♦ s ._, e E 3 3 L •• J E • •,• Z ..I is
_ -_ COMPENSATION INSURANCE
(This s zrior need not be completed if the permit is for one hundred dollars
1 certify that in the performance of the work for which this permit is issued, I
' -• - "— " - - "' - -' " - — '
ihall not employ any Person to any manner so as to become subject to the Workers'
,+
Compensation laws of Califomia. Date'
Applicant
NOTICETOAPPLICANT: IL ober making this Ccnificae of Exemption, you should
become subject the Worker's Compensation Provisions. Labor Code, you must
forthwith comply with such provisions or Nis permit shall be deemed revoked.
.. ._ __.
'I_
CONSTRUCTIONemil.cLENDING AGENCY
w Iher
- _ ....._ ...._. .. ._. ..
he 1 hereby affirm that @<rc is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3N7, Civ. C)
� Lrndcr's N8
miric
Lender's Address
...__ _V .. _..
I cenify that I have read this application and sum that the above information is
- 1 s
ma--�`
comply
1 agree to c car end county ordinances arta state laws elating
PYwith ai
to
m of this city reenter upon
ion:and heorinspction
asematives
the abo(We)agree
imovngcoanione mo
Pro pendforify
1. itknpurposes.
(We)dgmet, save, indemnifyitkeephamoral, theCityCupertinoagainst
in
liabilities, judgments, costs and expenses which may in any way acerae against said
Cory in consequence of the gmming of this permit. - � �
\i
' APPLICANT UNDERSTARDjjj,,,aaa•...a��.•'AA{� y��vILL COX 'Y WITH ALI. A/fgJ NT'
SOURCE REGULATIONS. S/l7OZ
Issued by: Date
Signature ofwpphcanVContramr Dine
Re -roofs
HAZARDOUS M TERIALS DISCLOSURE t
ivhime ipprcam p. fueee Wilding occupant store or handle hazardous more..[
�Type of Roof.
u def d by th Cu and Municipal Cade Chapter 9 12 ad me Health and Safety
Code Set 255321.1
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'
All roofs shall be inspected to any.roofing
N Il Ne apPl cam tutDyes
b'Id eg oc pa eq v ntordevices which
ems hmard a oat m t . def d by theBay Arco Air Quality Manugemem
poor material being. installed.
If a roof is installed without first obtaining an inspection 7 agree to remove
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OY
all new materials for'inspection. Applicant understands and will comply with
all non -point source regulations.." - --""
1 have rcud the huza Bras mammals requirements code( Chapter 6.95 of the
Safetyns 25505, 25533 and 25534: 1 understand that
(ache building does not ntlly have tenant. that it is my responsibility m notify the
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occupant of the mulaimmetns which mus W met prior a issuance of a Cenific6m of
Occupancy. -
• •g t!Z
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner er a mmda< age " Dam