02040032-- BUILDINGDIVISION,v PERMIT I CONTRACTOR INFORMATION: I
BUILDINGADDRESS:
10595 CULBERT
OWNER'S NAME:
MILDRED DAVIS
PHONE:
I-�:IM:IYYSakFT.GIIJRR:A
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (sommencing
=t, with Section 7000)of0i ,mo3ofthe Bmin,,,ord Profession., Cale. and my license
m y ,, ism full fn..a and effect.
m u < Lice se Cla.,s L¢, b
o L V Dale Contractor
r a to ARCHITECT'S DECLARATION
,g 1 understand my plorm shall be used as public records
o
p
:on
z O 4ccnuJ Professional
1 u= y that I a� exempt o DECLARATION
1 hereby ,Rath that 1 1..Bumps ,ram she beontmcmr's License ny c taw for the
t- a fallowing mason. (Saban 703L5. Business and Professions Code: Any city or county
Y B o which requires a permit re sults the
alter, improve, dcmmmin or repair any structure
a3� 'p^onoirs issuance also requires the uppli<am for such permit mile aaigned smtemrnt
that he is licensed pursuant to the pro %was of the Contractors License Law (Chapter 9
(commencing wish SeRitm 71(0) of Division 3 mf the Business and Proficiamms Code)
or that he is enempi therefrom and the basis for the alleged cAcmption. Any violation
- of Section 7031:5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
01, as owner of the property. or my employees with wages as their sole compensation,
will dothe work:' and the structures is not intended' or offered for sale (See: 70bL-
Bosiness and Professions Cale: The Commcmr's License taw, docs not apply to an
owner of property Who builds or improves therson, and who docs such work himself
or throwgh his own employers. providrA that such improvcmems are not intended or
-,offered for sub,.If, how.v.o In, Wilding of improvement ns Bald within me -yea, of
'completion, the owner -builder will have she burden of proving that he did not build or
improve for purpose of salt.).
�W/a e ame pr pc ty I v ly s i g wo,h licensed romraaors so
sbmousi the project (Sec 7144 Business nd Professions Code:) The Contractor s
License tow does not apply to an owner of progeny who builds or improves thereon,
..and who.contnets.fm suchprojects wish., commensals) licensed pursuant to the.
_ - Contmnofs License Low.
❑lam=a naerS c. .s y j)B r&PP CC fo/this resson
_ - - own
WORKER'S COMPENSATION D CLARATION
I hereby affirm under Penalty of jarjury one of the following declarations: -
i1 have and will maintain n Certificate 'of Consent to self-insum for Worker's
Compensation, as provided for by Section 37W of the Labor Code, for the
pe fmmanec of the work for which this Fr m , is issued.
_ ❑ 1 have and will mal -Wil Workds Colnpenmtion Insolence. ai required by Section
3700 of the Labor Code, for the pe forname of me work 'for 'which this permit is
issued: My Workers Compensation Insurance carrier and Policy number art`
Comer d.gjiC,,�'QF; .: Polcy No:'..-.,. ....
ms CERTIFICATION OF'EXEMPTION FITOM WORKERS
COMPBNSATIONINSURANCB',
't(Th s'ummn rievil not be completed of the panni. is for one hundred dollars
($1001 or less.)
d emfy that in a pcHo rnance'of th work for which this North is issued, )
ihall not employ any person In any manner so as to become subject to the worker
i
rc
Gom-mire. lows or rail-;. no,. .. .
marrowitit comply wish such provisions or this permit shall W deemed revoked.
� r -
CONSTRUCTION LENDING AGENCY
I henclaiR on that them, is a consiruction eisding agency for the performance
of thwork'f which this Permit It ssued (B 3097 Civ. C )
fe-'
-nd 'Name ,
.,. .. .._
Lender's Address!'
I certify that i have rad this application �and state that the above information is
correct. 1 agree to comply with allcity and county ordinances and state laws slating
m Wilding conswetion: and herby Imitable mpresenninves of Nis city to enter upon
the abovcmentioned propcnv for inspection puapo"
(we) egream save, indemnify and keep hannlesi the City of Copeiiiho-.,..at
liabilities, judgments, costs and enpenus which may in any way ec�rue egainsm said
Quit In can ... bro<e of mint' o niinn nf,hi•.,.....:, . . . „
7ic,?1
2EG.."AJ.,S.......,,...of APPlican0"amocmr" ^'HAZARDOUS MATERIALS DISCLOSUREl th ppl' nt o r t m W Id g« pantsloeo n dk ha>adom trial
by th C pen n M is pal Code Ch pte9 12 d the He lin nd Salary
n 25532(( -c a � _❑Nol the ppli ant o f t W lding p t equip e t d 'c . which
dens air contaminants as defined b) the Bay Area'A r Qtml ty Mangement
"' allo
1,
1 1 h ve oca Vhe h zurdops mngnals gmremems and r Charter 6.95 -of rhe.
ERMIT N0.
02040032
RPLICATION SUB DATE
04/05/2002
ANITARY NO. CONTROL NO,
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
REPLACE WATER HEATER.
,_'--l'13'2'3r6`.`0"°.ia��a:..'t '-
502""=' FTNAL PLUMBI
507 -FINAL pAtgmjfT#jY.9spections'',,
Lit®
.APR_
1 9 2002
_ .. _.___. ... ._..__.
$600
j D_i1.
m
Issued by: _e i &A�/�� Date
Re -roofs �
Type of Roof _ �. ...__,... � .�
Y ..
._ All roofs -shall -be �nspectcd'priorto any -roofing material being installed.._ _
If a roof is installed without first obtaining an inspection, 1'agree:to remove
. all new materials for inspection. Applicant understands and will comply with
all non -point source regulations
r o,. > emna my responsibility ratify
anclum f the '-quem nt. hrh must be - suer a of cars want
is',
_Signature of Applicant Date
w'r '"°iagent All roof coverings to be Class "B" or better' "
l - .. ... OFFICE_