00040018OFFICE
xl atiwcnivtsiov PERMIT
,•CONT'RTAWTOR INF IORIVINTIOO N':
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BUILDING ADDRESS:
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SANITARY NO.
APPt(CATION SUBMITTAL DATE
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OWNF'SNAME'
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ARCHITECTIENGINEER
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Ihereby afTl Nell licensed uunder��:Mf cooter 9(commencing
_ Job Description
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wish Sation 7000)mfDivislon3of Ne Business and Porlm.ioes Cada. and my license is
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infullforoe and arta SU
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DatcJ, rConuwtnr
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ARCHITECTS DECI.VIATIO J
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l undmurd mypWsalWl be usedas Wblic ruvrda
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OWNER -BUILDER DECLARATION
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1 hereby afrm Net 1 am erempr from the Contractors License Lew, for the
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following rcasmn (Section 7031.3. Business and PmRnione Cade: Any city a county
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Sq. Ft. Floor Area
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which outimee a permit to caasm¢l, Jur, improve, demolish, or repair an smemsre
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prior its ismance, also r boos, the applicant for Inch permit to file uiglled luutam
that he is licensed punwm to the pmvitions of the Contractors Ucwm law (Chapter9
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(commencing with Section 7000) of Division 3 of the, Business and Professions Code) in
Ndistinction he is eaempdistinctionW NN
m e basis for e alleged esempdon. Any s'iolation of
ppN Number
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Occas ane
Occupancy Type
. Section ]031.5 by any applicant I.. permit tubjo ss the applicant to a civil penefry of
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not mom Nan five hundred dollen
Required Inspections
❑ I, asowncrofdeprdpeny,ormyemployaawiNwegeeastluirwlccompcasaion,
will dothework,We; Iwcmrcuretintendedm an Runners
apply
and Pmfnalone (.'fear The Contractor's License Ldo dace Ild apply to an owner of
Lawt to
who builds or imp e Merton, and who don such wotk err through
his opropady
his own employees, provided Lha such improvements dad or
t art noron intended a oRercd for
,
sold
tale.If. hewear, Nh wildingoren of prmcnt it soldwithinioaild Oimprove fondu
owarbuildtt will have Nc burden of proving Not he did not Wild or improve for Pur-
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❑ L as Owmer of •.B csnessd.0amely con with Ors m
censused be c. Sec.70propert
alp esid. Co6:) The rmic.c
not (Ser. ]000, Catremore U.
brei
centses of
law daonotspur mus owner property who ds or pro
who buildssrs wine
yank
Couracsod
who ith.mfproperty
who wneactx for such prolan with a contrwmdO licensed punuant wine Contrwtda
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License law.
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❑lam aemRunder Seca ,BAPCfor Nislwan
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Owner Derc
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjuty on of Na following dalaruiom:
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❑ 1IsV<and will maieuin is Cenificne of Co.. to self-imurefor WohereCompen-
sstion m provided for by Sation 37W of the labor Cdc, for Ne pedomaae of the
h for which this permit n issued.
❑ 1 have sod will mainteln Workers Compensation Insurance, as required by Section
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3700 ofthe labor Codas, for the perfamaee ofd. work Imudich this permit is inti
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MY Wo¢Compenuti a cec 'awd Poliry
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Cmdc PolicNY
Its
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CERTIFICATE OF E%EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section ned not be completed Wits, permit w for on hundred don Slle1(0)
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in Icas.)
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I certify Net in de performance oftbe work for which this permit is issued, l shell
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not employ any perm in any menar an m to become subject m the Workers' Compen-.
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sation Laws of Califomia. Date
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APPlicwt
NOTICE TO APPLICANT: If, after nutting this certificate of Eaemprion, you should
he omr subject m Ne Workers Comperand. provisions of Ne Labor Code, you masa
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fonhwith comply wife such provisioes or this Forth shell be domed revoked.
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CONSTRUCTION LEND NO AGENCY
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I hereby affirm then there is aconswcuonlendingegency fm the perfomuoce of
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work for which this .it is isoud(Ser. 309], Civ. C.)
LendersName
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Lenders Address
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Icenify Nat 1 have read tins aWliniion end erne Net Ne above infonwtion is
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conal. l agrcc to comely with ell city old Canty ordimnces and sun bans rtWinB to
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C.)
Wilding construction, and hereby authorize repnunutives of this city to entei upon the
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above-mentioned property for inspecumn purymses.
(we) agree to sus, indemnify and kap harmless the City Cul, nino
of against
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liabilities, judgmeml, eau ad espemea which may in any wey (carne against said City
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in consequence of the gmnung of the perml. _
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APPLICANT UNDERSTAND.' AND . COMPLY WI' I ALI. NON -MINT
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SOURCE RF.GUI. S
4-5-00
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OlO %ZB.g/
Sigreto can✓ConRD Dam
HATARD US MATE RIALS DISCLOSURE
Re -roofs -
l the Wilding store hadlehrzalth us
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cd Casper ino Muni
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as defined io the 32(a)? no Municipal Code, Chapter 9.12, end Ne Health and Safety
by e, Chaps and Safe,,
Code. Section sss3x.)+ .CTS
Type of Roof ..
❑ Ycx
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Will the fmmrcWilding
All roofs shall be inspected prior to any roofing material being
epphcamor occupuntuse equipmein or devices which
emit hewdous air contamdnanu as defied by the Bay Arca Ab Quality Manegctant
installed. If a roof is installed without first obtaining an inspection
ietrinl
❑Yes 3 --
I agree to remove all,new materials for inspection. Applicant
Ilove ,rNnhaa timmmatamm
d ialsre9manmaerCh.g93
er6ofNeoli.
understands and will comply with all non point source regulations.
fomia Health R Safety Cade, Scctious 23505, 25533 and 255M. I understood Nat if Ne
hmkIingdmanmcmrmtlymvc ad t it is my rearcrabilly comity the mnt
<upe
of she reqbem
uenu ' W issue f.cppjtl upncy.
_. 77
,Signature of Applicant- ' Date
Owner Nor agent Date
All roof coverings.to be Class 'B"•or better
OFFICE