01020134 CITYOF G DIVISIO PERMIT
NO
BUILDIN
CONTRACTOR INFORMATION: I -
BUILDING ADDRESS: PERMIT NO. ,
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O\YNIiRa NAME-
APPLICATION SUB DATF- ,
hlf:E:P1T)Ic:Y :ff:)Eil_:F'II 611=IT) F':1:1 'F_li ;1'611=i1: :C 14,718IIFCFi:I:T7:f(-ll=I G1V i7ir /'r.'3L1!'c:Cl(il'J.
` 1'f10Nli: SANITARY NO. COND ROL NO.
(468)2810281
G m z ARCHILICDENGINEER: BUILDING PERMIT INFO
BLIDG ELECT PLUMB MF,CII
z$y= LICENSED CONTRACTOR'S DECLARATION
Iherebynmrmlhallamuamedmile,prnvi'm, Ifehn" teem.... n Job Description
oz=❑ ter` e -
F•v;7W
with andefillvivinn}nl'the liusinca,;uW Fmfmvion,Coati.unit my license '
-� in full totes and effectI.
REMOVE r'nF.T:f61F_ r,Ot:71 x REZROOF.,
z z% Licen.w CP 1_ic.p <
zIrm conuaetm 2 -
5a.0
ARCHI'I'ECI'S DECI.ARAT ON
3 I undershtw my plain shall be used as pubic recoNs
r
a,S: Lice 11 ..
f ' I '
LL OWNER-BUILDER DTCI ARAI'[ON -
='w I hereby offirra,that l am coolant from the Control LieCiccui Law for the
t?i
following rel sc 70315 Bmims,andl f ,Ca :Ay city m,ommy
d F8 which c,und,a p 't t 1.,,,toller,inn,poo,.dituoh,h,or c,air only.euchre 3
l— prort,t,nwanc<,alaorequire,the applicam for such permit to the a signed statement
that he is licensed pursumt to the pmvativiv of the Commrne,License taw Chapter Sq. FL Floor Area •tion
Rom ncocing with lection 716isi
X1)of Di, J of the Basile,and Poo—ion,Code)
or III,he i,exempt,herchant load Inc balls for the alleged excmp,ion.Any violation t,
of Section 703L5 by any uppliea.I for a permit while's the applicant to a civil penalty
,if am more than rive handled dollars fsAlo). APN Number - Oc upancy Type
01,-1 owner ol'tnc pnryeny,onmy employees will;wa6cs a,thelrsol,n,mproamn. -r. :y:)'a ;i':^i ilf8
will do the work,and the gmcture i,not intended or ollBmd for idle(Sec.)IW, -
Business and Professions Crete:The Commem,x License Law does not apply to an Required Inspections
..w r ofprnpeny Who builds or improves thereon,and who docs such work himvell
r,ivm;gh Ill,own a mphyeo,.p avi,hd mat sumo[,improvmnem-,are I,,,intended m 3@)'7
offered In sale.Il:h vve-r,the building or,mpmvernard is colt within one vear of 3@7
y
ry onpletion,the owner-builder will have the burden of proving that he did not build or
improve fill urpose of,ala.). •:pt!i/ ""1 ,I=h?t.i LAT],
._t i . ON.U
y p
❑1,aowner of the provedy,am exclusively comment ng with licensed commctorsm 6,01 — ROOF" TEf-1R OI'l=
consumer the project(sec.70,W,Bu,inevv and Rafessiom Crac:)File Contractor',
License Law does not u I to as owner of or su hn builds or imp 6:a!<lir.':.
nn r 'v w psovax mereomo
and who etatmctx bar such pmjell,with a coomachm) licensed pursuant to the
Controvi License ROOFT361T"T'I�'Ixlwi
law. —
❑IamexemptanderSee. .B&PC bethis reama (°iCaf.:1l.7 :I:Id-'•I�'Fii:7GiFtF-Sri .
owner Utile
W'ORKER'S COMPENSATION DECLARATION
I hereby aBlnu under penalty ol'pern,one of the billowing declaratlu;vv: -
O 1 have and will maintain a Cenilicale of Consent h wff insure for Worker's
compensation, as provided for by Section JWq of the Lahr Code, lot the
perhmnancIll the work for which this permit iv issued. -
❑1 have and will maintain Worker',Compensation Insurance,as required by Section
371X0 of the labor Code,for the perfurmmrce of the work For which this manna s _
issued,My Wn Lei',Cmrperomiun Imwmmcc rattier.,,it Policy ou I Li arc:
Cather: Policy No.:.
CF.RI'IITCATION OF EXEMPTION FROM WORKSS'
COMPENSATION INSURANCE -
Tbiv section need not be completed if the permit is for one hundred dollars
IF lap or le-,$) -
1'entry that in the perli,rmanee of the work for which this permit is issued.I
shall nor employ any pl—,a in any mon gyp y'subject to he Werke,
Couslulad�an haw,ul Clot�i�ru,r�/r.Data ".1- 1 _
hoemmem C
NOTICE TO APPLICANT.1r.' making this Certificate of ExemPtion.You should -
Z become subject m the Workers mrpemamon provisions at the labor Cede,you must
Z O liadwith comply with such al ior,lot this panni,shall be deenred revokeJ.
Z r
CONSTRUCTION LENDING AGENCY
7 I hereby affirm that form I,a con.umetion lending agency for the performance
of the wool,for I,hill this pm ui,iv Issncd(Sec.3097,Civ.C)
S A Lender',Natne
Z Lender's Address
U I certify the,I have read this appli,e, a und.ame thus the aleme infomnudon is
0 F to building I uconsmclinnelunw with
bereb city and county ordinances and state laws relating - -
�,,, :.I the abuvctnnNoacd n Introspection ic
rivor, fives of this city mentor upon
W Pmp Y poe ton pu
E.,
2. (Wc)ugrccu,scusty tunmify,tnA Aoph;may
Cityofemeaainst nd
fl, City in em udgmmpv,coal and eapcnms xhmh tnuy in any way oohs against aid
U Z Citylncon.vegUNDElthe ANDSgratin AND
permit.
'� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT .
souacE RFcm,nTlolvs. Issued by: Date
S,gnmum of ArphcanhCommcmr Date Re-roofs '
HAZARDOUS MAIERIALS DISCLOSURE
Wu1 the appucam m future hand'mg oe,.fc,a xoom or bindle coundoa,matcHlol -Type of Roof -
as defined by the Carload Municipal Cede.Chapter 9.12,and the Health and safety
Cole,section 25532(x)?'
0 Ye` ' >"No All roofs shall be inspected prior to any rooting material being installed.
Will the applicant building by he myAll. pm Qualitnt y
Mira which If a roof is installed without first obtaining an inspection, I agree to remove
conDi'mi nzallous air,romaminams as JeEneJ by he Bay Amo Air Quality M1fanagcnsm g p g
Di""C1" all new materials for inspection. Applicant understands and will comply with
�Y" - all non-point source regulations. PP.
1 have read the hmmrda s adamtiab requiremenu'uadcr Chapter 6.95 of the
Culili,mia 111.1 hh&Safety Cloth,Seen 1,25505,2953}and 25594,I undcnhnd shut
, the buildinghe o no,cum,Ishicvl I,enhe me,, it i is my reupomibilirymnatify the �/
oupam at he requirements wnicn must M mat prior m issuuntt of a Cenificme of
(k<upancy.
Signature of Appli ant Date
/h9_-/1,L..�� /7_ALT l
Owner or amhon dagcdr 1 ate All roof coverings to be Class "B" or better
OFFICE