01090079 CITY
I BUILD NG DIIVISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10531 S FOOTHILL BLVD WERNER GERTRUDE A 01090079
OWNER'S NAME: APPLICATION SUB DATE
WERNER GERTRUDE A 09/20/2001
PHONE: SANITARY NO. CONTROL NO.
�i1 0 0 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
gZpy BLDG ELECT PLUMB Mf'CH
E I.. .l I-1 1- 1 L:.1
iZ °j LICENSED CONTRACT'OR'S DECLARATION
y 1hereby affirm that 1amlicensed under provisions ofCloquar9kommencing Job Description
ME with Section 70010)of Division 3ofthe Business mal PmtessionsCode,mal mylicense COFFERED CEILING IN MS. BEDRM.
]YE
is in full fmce and ertecl.
-m License Class Lic.N
Dam
r 0 Fi,
ARCHITECT'S
DECLA DECLARATION
1 understand my plans shall be used as public rtcoMs
i
S o Licensed Professional
OWNER-BUILDER mtheDECLARATION
'-�y I hereby m(fimt that 1 ern,Buster from the Convector's I:Anne law for Ne
t z G following re season.(Saito 7onstru Bueinw and prolamines e.cledi Cade:Any city or coanry O O
which requires n permit m construct,alter,improve,demolish,or repair any swcturt
2 'Priarmi¢iuuerce,also requires the applicant fm sahpemuuo Rkeaigned
(tommrBcetma parsujimmNe prf Division me the Bacmfsl.and
Proassiam Cmr9 g ,�7�saa bT Valnatlon
(commenejng with Senion,T000)of DivisionJof the Basinev and Dnhssiam Code) (TIN r}3 q'1F�'110 7�,-WaT�,by t• j'j1'�,I,'i, "
or that he is exempt thertfroel and the basis for the alleged eiemp(oe.Any viahtian t
of Section 703).5 by any applicant for a permit subjects the Vphcma to a civil penalty
of art mom than five hundred dollan($5W). AP !�'• Oanc
101 ATION � ccu p y pe
C3 1.as owner of the property.or my employe With wages as their sole compensation, 1n2 - PIERSI
will do the work;and dm structure is n I molt o rod fo 1 7—. -
Bedrim and Professors carer Taec '.L art 03 - UFER Required Inspections
own, of property Who hoods or improves froom,and w - -tech rk h If `
m m gn n employers pravtaea th C= re a t intens r __ 04- - E ?12 !
;oF(ertd for ole If,however the building sic eat is' d with rte of ,
completion,the owner W Id es Wil heves rden of Frost - ihe OS - AN HOR BOLTS
improve f purpose rule.) "" SE R & WATER _
�I-es ownm of property am exdusiv ithb nuamr, O2 UN ERFLOOR PLUMBING
continuum the project(sec.To a,Bmine mad Pttfeaamr ane. Commerce03 ERFLOOR MECHANICAL'"
License law docs not apply to an owner of Property who holds or impreseslh�rcon,
and who contracts far rues Mi.with•comnna(s)licensed pursuers,o the 2 0 4- - DERFLOOR FRAME - - - -
Con.te.Lion.law.
' ❑1amuemptunder Sec. ,B&PCfmthisrmwn 205 - UNDERFLOOR'' INSULATION
owner 'a�urDaa�-i�.(�O!" 301 - ROUGH PLUMBING
RKER'SCOMPENSA COMPENSATION 302 - TUB Se OR SHOWER
I nearby alarm under penalty.arpedury one of the fallowing declarations: 303 — ROUGH MECHANICAL
❑ 1 have and will mainuim n C6nifnm,of Convert,o self-assure fm worker's 304 - ROUGH ELECTRICAL •
Compensation• as provided for by Section 3700 of the labor Code, for the
orfiermm e.of the work for which his Pinot h issued. 305 - FRAME
❑1 new and will maintain Worker's Compensation ltoms.,as required by Scomm 306 - HOLDOWNS
3700 of the labor'Cods,for the perfommnce a the work for which this pcmat is 307 - INSULATION _
Isi d My W k r's'C mpen au ce umer,1 ahmncancer and Pobcy nbsee
C'11 T CERTIFICATION OF EXEMPolicPTION MOM WORKERS'1 t'r-" ' 13 Ot9 'r i dE}CTBRI ORKLATII
j.
COMPENSATION INSURANCE - -- _ _ _--_ _ _
- --310," INTERIOR- LATH. .c,;; tr.
(This action need nil be'comPlnnd if the permit is for one hundred doll.
(S100)orless.), ., 311 - SCRATCH COAT
I wn!fy ohm in she peirartiuett of the wmk'fm which this permit ie issued,I 5 O 1 = OF FINAL NALNELECTRI CAL
Compensation laws of
shall not employ any Person in any manner an as m become subject to the.Workers 'Di NERDY
California. AIL
Dare
Applicard ' 502 - FINAL PLUMBING ENERGY - -
NOTICE TO APPLICANT.If afro making this CanlBcate of Faempdon,you should
z Iaromesubject sdbeW&ke,Compcnvdcatprovisions fthe Labor Code,y. am 503 - FINAL MECHANICAL ENERGY
G forthwith comply with such provisims ar this Form,an.11 be dearond invoked. 504 - FINAL BUILDING ENERGY
t' CONSTRUCDONLENDINGAGEJCY 505 - FINAL ELECTRICAL
aI hereby affirm that hem is'a construction lending agency for the perfor avow -
afthe work for which this permit is issued(Sic.3097:Civ.c.) , 506 — GAS TEST j
Lender's Name - 507 FINAL PLUMBING
Zanders Aedrtsr"' "
'U'0 Icrrofythan Ihave readthisapplicationandatuethattheohnem(breaetinnis 508 - FINAL MECHANICAL
W I„ correct.1 agree to aamply with all city and coumyimdimmene and auto laws calming 509 - FINAL GRADE
Q fJ the move-menswatl property
for inspection suthpupmeas. .vas of this city menta upon
w, me abI(We) greetdpmprtyrmfyandkpmpmr. . _ 510 _ FINAL PLANNING
g4 es,j agree israve,indemnify and keep ham y in an City of co magas against
said
rA liabilities,juduence, ftheandingoftiwhichmayinanywayaccrueagainstraid 514 FINAL PUB IC WORKS
U-� City tri conugmnce of the graining of thispesmit. '' WITH ALL
"
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT" �� �/s /f
SO CE RF N _ -0 Issued by: Date ice-/�
Signature of p scan✓Com.tor. .. .Dem"' . IV
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ,
Wiu applicantcarputter,building accupanl atm,almdle neiudws arateml Type of Roof __. ..._. _ _.. .. . ..
fCanadian' c Code Chapter and me Health and Safety r ,
'IIs/ ,
CiderOYi. 2j3.7 IMum. .-
Y )
° All roofs shall;be inspected,prior to any roofing material being installed. .. .. .Will the applicant or future building mcupam use equipment or devices which If a roof is installed without first obtaining an inspections I'agree to'remove
mit haaardous air communes in defined by the Bay Arm Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
e ores No ;t all non-point source regulations. ., !;_ •-
1 have read the.haaaNtus mamrdx rcquirenunu under Chapter 6.95 of me
Cdifomin Health&Safety Code.Saxons 25505.25533 and 25534.1 undmtmd thin
if the building does nofeurrendy have a tenant,that it is my mponsibility to notify the ,
occupant of the rcquin mems which must he met prim to issmn2e of a Certificate of
.. Occ ency. y�,
tao '"A'L) q-ZO-O [ Signature of Applicant Date
Owner mistiffisitA pro Data All roof coverings to be Class "B"or better
J OFFICE