01010128 CITYn owe oPEsRtoNNO CONTRACTOR INFORMATION:
PERMIT
auR.DINCAooxEss: 1.0W12 F.IRWf:l(:1D Df' _Ff:IUR lStF11SC11+IS Ii47L I �+�i No. f]].L�:I.f!)].i�0 .
OWNER'S NAME'. ' BERN+ Tl'ifJVV-'6 E,A`:HO�\9+ING ST• APPLICATION SUIjr�GjyCrlf!1�.
ION SANITARY NO. ll // CONTROL NO.
ARCHITECT/IiNCIN[ER: BUILDING PERMIT INFO
C w t " BLDG ELECT. PLUMB SUCH
Nzw CI O CJ LJ
y
'LICENSED CONTRACPOR•SDECL RATION
z 5 y� Job Descri tion
o z_0 1 hedeny nrrrm In;n ntn licensed ntmar pr,aivw x nrenaprer 9(enmmendng P .
with Seetian]nnq of Divisinn0al lha Business pndP hf..ion.Ghdc.and mylicenne
a ed f is ce full❑roe and er' I. '] o •1:zhlCil_f' TO (..IJI*0"5.7 a.T.TICIN _
E5eda Died
Chnes_� _ _ liesh -
ad a.U D'Jlo `�/ �O i CDECCh,l
w 3 u,'d ARCIiI'l1iC'r'S UECLARA Of
O-c 1 undentenrl mY Plans,:lilt be used as public rcnnm - -
Y
OLicensed Professional OWNER- -
Psciall'R DECLARATION
a I hereby.(Sot on 1 ten uxtmpl from Inc Comms Any City
Lure rnr the
k•Z 0 toll g (Section]TNI 5 Biomass J Professions Code:, A Y . ounp, -
p[O wM1 ts : e, II I I t p t Ln p y,tnaure
f-Q that I I I. y theliar applicant for such TI rl g linemen
i>i>5 onto 1 aP tl m p n rin Contractors e1 (Charter 9 Sq. Ft. Floor'Area Valu tj �
or
g with Section 91X10) 1D' ) III l Business nddda.Any
n,Calvi
or Sec Is s e npl theruf out nd the hasp for the cts the exempnt to Any l pennon
of do( ,, df 1315 by unyapplicant dredddllf,, apvnni,.eihjecty the applicant taocivil penalty _
our ern onto m;m once hundred dadars(ssnB). APN Numb erfry Occupancy Type
❑1,an owner of the pom
pery or y employee, c
with wage,is their role ompens:nirm.
will d (lie work,and the structure t intended or oflered for isd (Sec,70
Business und Profession,c d The C I n :ro Law do,,par apply tam Roll �lnspectl0r[S
w fproperty Wh h ldapprovesth n J h d h' rkhinself - w�L:.S '1'U ll'
our through his n npl Y pro,tried that.act, lopowerrents are act intended or
off e dt : If h In n it i g ':p e ti d withinn year of
enirf rlh naiel will have n de,or proving,gm In a"e out bh-mor• 601 — ROOF '1-E.R OFF
coup the osv r
❑1,u,owner of the pu rty,our exclu.mely contracting with licensed contractors to f.,p.p1i-'y. 1i3OOF* C{-'9/..�.YWYC•JYoDR hIf-)a'I_
enstruct the project(See.]w4,Buse,,and Pmfea,ion,Core:I The Contractor', �>(a�.) —' I'\l.lVl'• LilyT I 111`L.r
Construct
Law doe,ao,apply In on ownvnd Empery who builds of impmvc mereent. ,
- and who comnact,for much projects with a coutioctor(n)licensed porsu tet to he P[7�+ — I4(7IJF IN;1=9i0CilyESS
Common,,Llcenso Low.
O l um exempt order Sac. ,B to P C for this reason
Owner.. Unca a
WORKER'S COMPENSATION DECLARATION.
Ilmdeny uffinn under penlJty nfpepury one nrlhe fullnwing dedorm'mns: � -
I h I will t Certificate tC t I f Worker's
�
Ca
p C provided' f by Section it the1Le! Code C l-
the ��
P
r r tl k f h'1 0'.I t i'oa:. r. - '
11Th J will riot W k C pe i n In required by Section -
3708 1 the Lot Code,for mo pvrlutm ee of the work for which this permit is
i—ed.My Worker's Compenmtioi Insurance Currier and Policy rainber va. -
Carrierjqr;loc"�� C r Policy No.: (� Y3 - - -
CERTIFICA'fION or EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE ,
(This eland neer)nm be compleod if the permit is nitrate hundred Jnllnro -
(II00)urlcnx.)
I codify tharin Inc porlonname of the work for which this,somal is issued.l
shall not employ any person In any intoner xn as In hectare subject to the Workers'
comperoalton lawn of California.Doc
Apoieare '
NOTICE TO APPLICANT:If,after n eking this Corti of Biscuiptinn.you,hnuld -
botno subject to the Walker,Cnmptrvvndnn pmnsf mmu
vi,inoe iCood.you st
Z 0 ee
forthwith comply with such provisions or this permit shall he deemed revoked.
. z ..
Vit CONSfRUCTCON LENDING lending
AGENCY -
of 1 M1crcor affirm That thellpens[xs Construction Icnding agency for the perfonnanev
rZ Lethe work for which this pormil by lasued(Sec.20)],Civ.C.J
(,� Lando2s Name _
z LendoisAJdreas r
V I verify That ren
I nave d this npplimnom tent the tion and shoot information is
F cnrrocr 1 agree m u,mpl,with all city and county nrlinance-a end mea lows miming
V Mbuihtlng construction,and hereby amherue drousonteioes of this city to enter upon
the M
pe
O.t (We)age1 'd IY Ik for ir,pection pn
taintless the City ofC I i noog, lit
F Vl 'liabilities, dg .t d expenses.1bach-ny in tiny 'Y richest - ✓ 5
�.) Z, City lucoe of thegrating of thisportion. JT EJ
"' APPLICANT U RST AND WILL COMPLY WIT A ON POINT Issued b �/
soulxc Lr ATIo _ 7 � Y I=�A.7�� lip• .Date'
Signnmrcof phcatNComracher Date Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE.
Will the at,dicmn erruu,nuildingeecupsm,Inde...[:radio haaarlov,material Type of Roof -
as refined by the Cuperoo Mnnterra?Code,Chapor 9,12.cal the Health and Safety -
Gde, e Yes n 25532(a)1 No -
All roofs shall be inspected prior to any roofing material being installed.
Will medppueatn afuun)n11tido,wtupanl nsncanip.ircup device.which . If a roof is.installed without first obtainingan inspection, I agree to remove
nit M1;vuNnux ter coeoalmon"Wtl fined by the Ilay Arer Air QmOty Management P g
ismiviy �1 all new materials for inspection. Applicant understands and will comply with
OF ❑Yes Elton all non-point source regulations.
I have readth h I Ir'alChapterI -
y I: J ons lime /
Cal,fiverie Health&
' 'Sale(, J Sectors ad 25134, J t dthm
flhhld gd act ale rn,thtu,s y pYIt
� Paannnl Ir yuwhich moat he flip poor to lint edofaCertificate(it
'
/b
- Sign tore of Applicant' Dale
aehmired a,ord Date All roof coverings to be Class `B"or better
OFFICE