00060187 CITY BUIOFNO
NG DIV SION
PERMIT CONTRACTOR INFORMATION:
B17IN(iA RF:Sg [�Q PERMIT NO.
is/
no 7
OWNER'S NAMIi: ; e /101 E(`J; _ APPLICATION SUB LAM _
PHONE: -�fff •^•M SANITAR 'O. VTROL NO.
3 373 � 14306
❑re0 C ARCHITECTIBNGINEER: // Bull DING PERMIT INFO
ELECT PLUMB MECH
V I� LJ I_I
Z = LICENSED CONTRACrOR'S DECLARATION Job Description
1 hereby al nail that 1 am licensed under provisions of Chapmr Y Inmmemmng
FfntW withsection 000)df Diviatn,3of the Business and l'odessioto CUJe,and my llcensc
2] is in full fo a and t�
re K e.6 Licen ✓ Co tr_ 7 U
V
0. ti
(J nate Comrsn,r O U
3 a G ARCHITECTIS INZ,AR TION
to
O I undersand any panus shall be used us public records
Licensed Proles+ional
�y OWNER-BUILDHR DECLARATION
I hereby affirm that I am exempt from the Con ractoh License Low for the
f-ZQ following server.(Section 7031.5,Business and Pmfessionv Cade:Any city or county '
E o which requires a permit to svnsvuct,after,improve,demolish,or repair any strocmre -
63$ pound its issuance.oleo requires tM1e appaicam for such permit to file�sisntd amemem
that heislicenenl pennant totheprov,sidnsofthc Cantmcmrs Lecro,ias Chapmr9 Sq. Ft. Floor Area Valuation
(commencing with Semion 7(MO)of Division 3ofahe Busine.ssanl l'rolessions Code)
or that he is exempt therefrom and the anis Ino the allegro exmnpllnnAny vfalmitin
of Section 7031.5 by any upplican,for a pcoun t subice,the applicant an a civil penally
of not are than five lmrdred dollars S500), [/ •'')APN Number - Occupancy Type
111.as owner of the podiatry,or my employees with wages as their anlc compensation, 3 7 L' U L
will In the work,and the mcwre is ren intended or offetcd for sale ISce,704t,
Business and Professions Code:The Contratnr's License Law does not apply to an Required Inspections
orrodpropeny Who builds or improves theoun,and oho does such work himself
though hu own employees.provided that such Improvemums are not intended or
offered for ode IL however:the buiding of!,,I enren,is sold within one year mI
nmpleamr,theownerbullder, will have the hurdnt^f proving that he did not build or _
_ Impove for purpnseofsala).
O1,as owner of the popeny,am exclusively communing with licensed contractors to
construct the project(Sec.](kJ,Business and Pofesaions CWI:)The Contrnnoo's /
Licca Law docs not apply w an ow net of propcny who builds or improves thereon.
and who contracts for such pmicco with It contmcor(s)licensed pursuant to the
Contremors License Low.
❑I am exempt tinder Sac. ,Il A.1'C fur this reason
Owner Date + t ( )
WORKER'S CO59PENSXFRXa DECLARATION VI '
I hereby affirm under penalty of perjury one of the following declarations.
c) 1 have and will ran om a Cenifca,of Convent to pelf-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Cade, for the '
performance or the work for which this permit is Issued.
have and will nutinmin Wmkcr's Cnunponnut ion laomea,e,as Itgniied by Seedmm -
On of the Labor Cade.for the performance of Ole work for which(his permit is
,.slued.My Worker' Wal n l vance carrier and Policy umber arc:
Cameo_ R-1Policy No.:57� -(�
CERTIPICATI NOFEXF.MPIION FROM WORKERS' -
COMPENSATIONINSURANCE
(This section need not be completed if the pcfmit is for one hundred dollars
($HIO)or leas)
I emidy that in the performance of the walk no which this Nanit is issued.1
shell not employ any reason in any manner an as m become subject in the Workers'
Compensation laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificatn of Exemption,you should '
become sobject o the Workee,Compenatiuse
n provisions of the Labor Ca ,you most
Z 0 fonbwin comply with such provsim s or this Iran shall be Jwmcd revoked.
52 CONNrRUC'[ON LEN III NO AGENCY
a 7 1 hereby nation that there is a mninalion lending agmtcy far theperfornance
of the work for which this permit is issued(Sec.3097,Civ.C.) / O
L Lender's Name
z Icnder's,Address - /•I/
I+a O
correct.
cenify that I have read this application and state that the above information iso
[-. rrect.1 agree in comply with all city and county ordinances and state laws reaming V
m building construction,and hereby:mlhoriee representatives ofthiscily w eructation
y rye
the aid,ve-mealioned po pen,far mx"IlL n purposes. .
Ge. 4 (We)agree m sane,indemnify and keep burndess the City al'Cuponitm against
..I V1 liabilities,judgments,costs and expenses which any in any way accrue against said
V iZ� City in consequence of the granting of this permit.
APPLICANT Off s P AND WILL COMPLY WITH ALL NO pO1T
souacE REcu o. s dIssued by: ' Dale �0
Signuof Aptilicaro'o. r Dl Re-roofs _
HAZARD Us MATERIALS DISCLOSURE
Will the appbrm of future banning ocenpunt xmr,dr hundld haaardda•tnmend Type of Roof -
us denied by she Caticnino Mmuripel Crdc,Cl,upter 9,12,and the IIcahn and Safety
Code,Section 45932(,)'! -
ClYea "�" All roofs shall be inspected prior to any rooting material being installed.
%'fill applicant orfuwrebuildingtrcutiamuseequitimcmfirJcviceswhich If a roof is installed without first obtainingan inspection, 1 agree to remove
mit haitain airedntantinams as defined bythe Bay Area At Quality Management P }'
imri.? e� r all new materials for inspection. Applicant understands and will comply with
all non-points ce regulations.
1 have rend he ll;waolaaety Code,materialstios2 nalu 505,25533annera under 4,1uChapter h stand the
Cilie lain Hndth,Snotty Code,aveuo ental.
thinit 33und2557J.lundernond that /
dthcbnilding Jncs an curently hmeatenant.that it is my respunsihility to notify (v to OO
occupant of t e rc idents which he must acct rim issuance til a tpnific to of
Occupant /F'/1�O
G Signator of Applicant Date
Owaao,nathOrizedt One All roof coverings to be Class`B++ or better
OFFICE - - -