01060107 CITYBUILDING
DIVIISSIIONNO
PERMIT CONTRACTOR INFORMATION:
r��T r .t'
BUILDING ADDRESS J/v SO I �Q I lryC PERMIT NO.
10423 S DE ANZA BLVD 5@U Awl'I O:n;1O "— GN 01060107
OWNER'S NAME: 373 L /` &K PK< DkAPPLICATION SUB DATE
,,.CALI EDWARD S TRUSTEE 51t B±VT 06/19/2001
r PHONE, SANITARY NO. CONTROL NO.
(408) 339 @40'0-97d -3373
:]o z0 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
be BLDG ELECT PLUMB MECH
Hai CJ I ' I L_J LI
zi LICENSED CONTRACTOR'S DECLARATION DECLARATION Job Description
0 a`= 1 hereby uffrm+ha I am ImenseJ under provisions of haper 9 ommencin
py(_u wiNSeaion70001ofDivision3otsheBusinasandProfess ns Code, dmylicen REPLACE SEWER.
m Is In full forceand
z d a LicenseLic.p
X 0 a N Dam - cnnmwmr
uniAI CHITECf'S DECLAR 1
d U'an x xM1.11 be used as public ccar
d
,
s a
an a O O
°'ca b Licensed Pro(esziowl
, OWNER-BUILDER DECLARATION
C1. 1 hereby affect this 1 am exempt from the Contractor's License Law for the
F z'a Inlmwing re,^nn.(Section 7031.5.B i,ine,.and Probsxiorx Code:Any city or warty $3000
f xF o which requires a permit to construct.altar.improve. structuredemolish,or repair any structure
x- .prior t it 1x ' to also rc,moo.dbcppl' f .- hp n file a. J-uummm,
�-
'hlLt bc rc licearcidp'n ttothPro% ons of the Contractors Licenvt1-s (Chal,wr9 f1 1 ° 1:'. . - -Valuation
(co ening with Sxio 70001 f Division 3 of the Business d Professors Cody ' ^\. '� 35�k%ll'V! , t k i ��
or mm he is comp,ihcrcfrom and the basis fine the allkg<J exemption.Any violmion I
-of Section 7031.5 by any applicant for a permit subjects she applicant to a civil Penalty
of nm more than five hundred dollars(8500), 3 0 5APN DI f;"',• :• , Occupancy Type
01,as owner or the property,or 1ny employees with wages as mel,sole compen.vlim. i
will tl 'he work,and the sw t re'Is not intended' offered for sal IS lou' -- --
'Biciiiiiis amVPinfes,mart,Cm The cot t L Ln.ane, ma applyt 601 ROOF TEARtgpVg'Inslieetions '
owner ofpro,orty Who builds or improves thereon, d who does such work himself
or hiccough h's mart employees,provided m t cn improvements on,not intended ca, 602 — ROOF PLYWOOD NAIL
,offeredr I 'IrM1 1n b Ie'ago p t '-la m' r _f 603 - ROOF BATTENS ' -�t7.
completion,Ne owntorbitiker will have the bud fp -ng that he did tbuldo
rap for purpose of 1 604 — ROOF IN—PROGRESS
❑I owbronco, _.IN_P._ROG.
RESS
,hl -dc to
construct theproject(Sec.7044 B d Profession,Cod )The Contractors
fish p pent lye .
1
License Laws does not acridly to of property who boulds or improvesUncover,
1 - .,• "
_. -and who.contracts for such projects woe. commicamsl licensed pursuant to the
Contractors License Law.
01 am exempt under Sec. .U'&P C fortis.reason ;s _ 'i t
D;mer Date
WORKER'S COMPENSATION DECLARATION
`L I hereby uffimt under penalty of perjury one of the following declamions:
0 1 have and will maintain'a'Cdnificuc of Cdn.icul'to ulbi oom for worker's
_ Compenvtion: es provided for by Section 3700 of Ne Labor Code, for the
pe anee of the work for which this permit is issued.. ,,..
W o 'Sad will in5inialb Wdrker's Compehsniion Insurance,as na,unred by Section
f the Lsbur Code,for the poffca ace of the wmn,c7m which this permit is
issued.My�lWoorr�keer'ssCCom�pennssation Insurance carrier
CarrierCERTIFIC T I
F�Pd cy TI li MW` O`'RKE"RS'} 0 !' .. a s [.
COMPENSATIONIWSURANCE
. _.. .._..... .. ._-, - .._.
- f
.. .._._ _......
(Thrs seaian'neco not be<nmpincd if the permit is for one hundred J°Ilars - ` •r ` . I
151001m1ess.l _ '
n .. -
len fY shoe the.peA o of the walkf hivh his percent e _ ._ ....... . ... � .. ...-.. -_.- ._ _ -, .. .. . .--._.
shall im coat peen y mann r as 16 become s b)em to the Workers `
Compenmunn Laws of C 1 fomta.Date ' ' '
.
Aplifictaid
NOTrCETD APPLICANT
O APPLIeANTII making Cnf fExemption,yshould
z bemcn the Kok t Compensation p
o fionp of the M Code,you most
hhop1Ywi . h previsions othpmshall deemed revoked.
'r\
r
CONSTRUCTION LENDING AGENCY I:1
1 hereby off chat inert is a constructiondng agerwy for the performance ,
W_— of dr ork for which his permit ' .sued(Sec.. 3 97 civ.C.)Lender's Name
'
. ...... ........ .�
U 0 Icenry,that lluvereuldidnappftemiooand state that mealsove inforounor is
O [-1 Derei 149 t ply th II city and try d d scale s rcl'tinglumildinp
'(UTI the ba 6 ti edp iYf by pen x rep t i fm. tYr ¢ Inn \SII\--'`wt�y
b p4 g .i sx J tfyd k phi I sine C'iy tC pen nog 'nn
VI habit dg et < us in
of . heti y' y y ia,, aid VIVO "Ill
V Z City n yuan of he gr t ng opv iN'R '
APPLA TW,p.R TA'D A\D 'ILL COlIPLY H ALL N
NON PO
OUR ouR E EG ,rl N r ,. _ Issued by: Date
i
Pppr, nn °ane: Dale': Re-roofs
4 Jefi el HA RDOUS AT RIALS DISCLOSURE:"'
lmcappficantdrrdrn riding«cupamstore or handlenaxardnasmamtia .Type of Roof.
as h,ihe Cu Winn Municipal Cale.Chapter 9.12.and she Health and Safety
1
Code,sretinauv_'(a) - '
All.roofs shall.be inspected prior,to,any roofing material-being installed.
Will'hgpplic 1 f building spam me egip 1 rdevicex rich.- "
cm rhoe b coria r a'declned by the Bey Area If a roof is installed)without firs[obtainintr an ins ectiori;I'a�ree)to remove
- Quality ry htanagcmcm b P b
•Dix"" „ - all new materials for inspection. Applicant understands and will comply with
ov oN°- all non-point source regulations.
.. ,. - _
'1I huv read the h and u:material. q ' 'eau inJ Ch pt 695'of the -
Cuff inH alth&Safer Cole Section. 5505 5533 and 255.14.l understand that
ifinebulldilg•dnesnmc rtemly haecut ant., Tit is mY rexpdmibilitYm notify the "' - "' '- - -- -
"tura o the mq ire cats which mu t be et prior to issuance of a Ce74 nifcate of '
1 O cup:try - ..
Signature of A heart
--- g PP . .. .... . - ' Date
an ont Date All roof coverings to be Class"B" or better-
%:..f OFFICE .