01020011 CITYOFDIVISION
VNlvo
NG IISIOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS � / - PERMIT NO.
OW NA �A/V� _ PLICATION SUB DATE/ _O
ruorvE:E: 73 -qv-7
GV- SANITARY NO, CONTROL NO.
C.aeZ ARC'HITF,CI➢F:NGINIiER:
E O O BUILDING PERMIT INFO
a
O BLDG ELECT PLUMB .MECH
a
yF{6
O v=Nii LICENSED CONTRA CaOWSkerp DECLARATION
Chapter
'Job Description
o z—o I penny steam lite I anti licensed ander vrovismns ar enaptm9(commencing
x ; with fall
Diviainn3nf tete Business unJ l'rdcssinm epee.and nmy license
in nal rause aw elr•at.
s a ) class Lie.r
m
3 0 Dao,ara Commor
ARCHITECT'
be u•e DECLARATION
I uudcrsl:Inrl Illy plans shall be used DECLARATION
TI Ns
wd O O Licensed Professional
62ei
a� OWNBR-BUII.DHR DECLNtA'1'ION -
1 hereby affix n(hal I am mrinpi loanComm
rt,,,',the Comctnh License Law battle
!-Z< Illicit retuon.(Section 1031.5.Business and Profcssiom ColletAny city or county -
F C which requires a permit m enn.mmet.alter,impulse,demolish,or repair any slnlamre
{yam prior al its issuance.also requires lheapplicanl for such Penne m file a signed sla4mmcm
h That he is llmnwd pllrsa:olm me pmvi,i If the Contracture Liaeme Law fchapler9 S Ft. Floor Area
(commencing with Section 1(XX)I of Dili,ion3 of the BL.nles,ane Prookoin,Code) q• Valuation
or that he is exempt therefrom and the hasi.s for the alleged exemption.Any violation
of Sectio 1031.5 by any applicant for prinll aincels the applicant m it civil(malty
ar urn item's d,an livhe Nohundred
ly.Ofmy empllars loyees
�PIY�Yfber Occupancy Type
❑l,asownvoIf he propny.ter my employees wish wages as their sole cnmpnwlion. ((J GS
will do the work,and the slruemre ie nal Intended or offered far sale(See.91W4,
Holmes,and Prarcxn;alls Cndc:The Co..washr'e License Law does not apply to an Required Inspections
owner of poppy Who build,or improve,(hereon,and who arcs such work himwlf
or through his own employees.provided that such improvements are nal intended or
,ifflood Include.If,hoste""na,handio, ,,hapno,rocan :. id within not, of
ar glome 111 IIhh dl lP 'ng tete Plltbuild a
alp e f r p rya f l )
�1of the m1 p .ny, 01 i :iv ly c t I i 'IM1I J 1 I r,
nl Ile Pjeer IS 7044,13tll ltao uCd ) ITC tet :
1.ce 1 hies nonapplysuch
t cal p p fr who bniic. Improves thereon.
and who contracts for such Pmjeas with n comnemrts)11C[n.iCJ pursuant nI the
Conlracuors License law.
❑tum �pt ml IS- It&P C for this reason '
OItKER'S COMPF.NSAIbN DIiCLARATION �(
I hereby affirm under vewlty of perjury alcor In,following declarations: a Q
Cl I have mW will red-trin it Cenificnle. of Consent to edGirtmrc lirz Worker:,
Camgcnemion, a, prnvlded Ins by Seninn 3100 of the Lahm Crvlu for the
performance el the work for which this Penni)is is lied.
❑I have and will mainmin Worlom*s Comper tion Insurance,as reyuired by Section
391111 of the Lubar Code,fns the periorounav of the work for whish his pmlu is
,ned.My Worker's Compensation Inwlmwe calf trod Policy number arc:
Carrier: Policy No.:
CERTIFICATION OIEXEMPTION PROM W ORKERS'
COMPENSATION INSURANCE
Otis section need not he completed it the prnlil is for one hundred dollen "
IF 1(10)or less.)
1,miry That in the performance of the work rnr which his penin is issued,I
shall not employ any person in any manner so as m become.subject In the Workers
Compensation laws ol'California.Dote
Apphcam
NOTICE TO APPLICANT:If,after nuking this Ceffi ieate of Escmplion,you should '
Z become subject to the Workers Compensation provisions of the Lanor Code,you most
ZO ILnhwi0l comply with.ru,ll pmvisiom nr this permit shall he leaned revoked.
Z
F ^
CONSTRUCTION(.ENDING AGENCY
C , thereby frontwhich Ili,therein acan.d(Set. (cath ngvgcncy Ill,the pmlinmmma
W of the work far welch mss permit is IxsnaJ(Sec.3009,Cie 4) -
LY Q Lender's Name
5 Z lender's AJArcsz
It.
[love
I agree to c comply
road III[city and
county rain hot an statent, laws r ati i, -
(, nlrrem.1 agree to comply wird ell city and county onllnanees and sate laws miming
U albInkcegcumyued po,ndherchy pectiimrepmwnt:nives oflhis city to enter upon '
the uM(We)a,,lu,m propny far impclion purpruile
cs,, dyne:msavc,fail sk,mos'.10 hmay in the City ar Cup naves sad
LLLLIIII Vi liabilities,j"tunces elms and uapense,welsh may in any way acerae agvinst said
(,7 Z Ciry in enmwyuenre of the gnnlin o(his pnnit.
APPLICANTU ERSTAN DWI OMPLV WRH ALL NON�PO
'OUECE I A L ------ Issued by: Date
signals Pelican Cmm�ct Ic Re-roots
.HA'J.ARDOI)S MATERIALS DISCLOSURIi
WII lno-upplicumnrfinme bulldllgxoupant alum nr handle hl¢nnlnma ma@nW Type of Roof
as defined by the Capella Municipal Calc,Chapter 9.12,and the Health and Safely
Cade,Section 25532(.)!
oyes ❑No ' ' All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future building occupant use equipment or devices ubich If a roof is installed without first obtaining an inspection, 1 agree to remove
mail hazaNnm air conuonin urs as defined by the Bay Area Air Quality Management g p g
District? •o No, new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have read the hazardous na tentrls uspiomems under Chapter 6.95 of the
Calinufma Health k Safety Code,Sections 25505,25533 and 25534,1 undcolnnd that
if the building does not a bully have.(mane that it is my responsibility to amity file
Xoccup:ml of the requirements ''h must met prier m issuance of a CeniEcafe of
capaney. Signature of Applicant Dale
owner ntnaramagent "--S>„e All roof coverings to be Class "B”or better
OFFICE