01030022 CITY G DIV RTNNo PERMIT CONTRACTOR INFORMATION: -
BUILDING ADDRESS'. - PERMITNO.
21891 GRANADA AV ADZICH HELEN AND R DOVAN V TRU01030022
OWNER'S NAME APPI.ICATION SIM DATE
ADZICH HELEN AND RADOVANI V TRU 03/06/2001
PHONE: SANITARY NO. CONTROL NO,
1900 ANUIIIELT/ENGINEI!R: - - BUILDING PERMIT INFO
ze(� PLUG ELECT PL IhIB MECH
.fi 6 i
Z,<
LICENSED CONTRACTOWS DECLARATION ]Ob Description
t
O T.ln O 1 hereby of ion Inn'1 tan licsssed under provisions III Chnpmr v(contemner,
rr,�to with Sec'ion'IINX))nfllividnn7nl'Iho Business and Pmfrnions Code,and mylicense
<xf; 'c;nrnurnra aen'eet.
IGAS METER.
gs� .Wo,r Class Lic.«
W B w h lateSEFOLm l�
O AliClll'I'IiCT' DIiCLARA'TION !/ /
C } I understand my plans shall b...J as public oremd, /
wa p O Licensed Professiored
OWNER-HUILDER DECLARATION /
hereby nip rtn that I ant mxempt from list Count cmr's License Law fur the
C>Q Iollowing reason.,(Section 71131.5•Business end I'rn4se;nn.s Code Any city or county -
'E� o which requires a permit t -I t,alter,inuprover hemolish,or repair any vauchure
Ls13 rest aaa,illvas Ice al,illth mpl nt unlaush pe.it fil,it,i,imdallonabot
that he isIce scdpursuant tthe pool pion,of beContractors l LIiw(Chapter 9 S Ft. Floor Area Valuati
(co m 6 with Section 7000) fD 3 1'h Business dProfessionsCode) q' gn
or In,,(he is eveno,d'M1rcfn n auldm hu'. ke Jlegul uxnptan Aty vtkmmu $0
.1 Sen of 7031.5 by any it,mi,an'Iafu perms subject.,the applte:mno o civil penay h09
of not-.re'linefile hundreddnun'a(s500). APNNumber t OccupancyType -
❑ha,.wner rohne propenxmtny empmysxa w;tb w'agmemmeh sole ma.pcmaion. 35710
6019.
will do the work,and the„rnnure is no'intended or Inherent for sale(Sem.7(144,
Bn>inea,i J Prefea.ionn Cod, he cono-nn...I.volosc Law It.it.,.,ply Inn. Required Inspections -
w r of ropeny Who build,or inlproves dw n and who Jct such work himself
o' mr.. his ova emple,ed,.provhledm w h'im...ro are Intended oe 106 — SEWER $ WATER
f rc If.however,the g r i movement is I 'nyI one rear of
col 0d:.I 'ow...nnade on, a men no flow, I It Whi,'I cm b ld or 202 — UNDERFLOOR PLUMBING '
Id ve m or..`e.r'`rm 301 - - ROUGH PLUMBING
Per B wdhncedThem '0 302 — TUB & OR SHOWER
u mc'the pmjcc5(Sec. <,Ilusiness an tofess ns Cale,ed Commerce's t
1.we saI ww does not apply r.an.wnernfpr. my whe builds.r mummer,tne'een. - 502 — FINAL PLUMBING ENERGY
and woo commas lar such projects via moremrrs)I;cemed proment In the
C...irad.rs ueen.e unt. s 506 — GAS TEST
❑1 not comm,under Sec. H&P C for this reawn
0,nmr Date 507 — FINAL PLUMBING
` WORKER'S COMPENSATION DECLARATION
b I herehyaltilm under pemJly.f perjury.ne.1 he following declarations'
❑ 1 here and will maintain o Certificate of Consent m,xlf-insurt fur w'orker's
Compensation, a, provided for by Section 37W of the IaMr Cale, for the
per(nrmnnce of the work for which this permit Is Issued.
❑I h:ne and will maimam w'orker's Compensation]a...ant'e,as required by Section
37m1 of the LaM,r Code,for the performance of'he work for which this permit is
sued.My Workers Confirmation Insurance easier and Policy number ate:
Carrier: Policy No
CERI'I FICATION 017 HXEMPI'[ON FROM WORKERS'
COMPENSATION INSURANCE
(This section aced out k completed if the permit is for one hundred dollars
($1 W)or less.)
I cer'i I that in the perfornnmce of(he wild,Ior which this peri'I,issued,1
shall not employ any Person in any manner so as m become.subject to the Workers'
Compensation Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this C'mdene nr Gumption,you should
he...lum,uhiect ,, he Worker's Cntnlwnselion pmvlsl.ns of the Labor C(do.you mus'
Q Q fnnhwi'h comply with such Provisions or this Permit shall he deemed revoked.
f h CONSTRUCTIONemisacLENDING AGENCY '
I hereby aflich that Here iss cont(Seen lending,C.) for performance
III I-end work for which Ihis,anuli is issued ISec.3497,Civ.C.l -
0. Q I.elWer's Name
z Lender',Address
V I cenify the,l have n ad'his applicmmn and sm'e ded the oM,ve infomm'ion in
�+ (r
Correct.I agree to comply withinI tY and county orthoinces and state 1 elating
Q V building coo cluncli'llo. dl by Ikon n tv s ftl':rily' t r u,mn
y ry) me n atened, ,ny Tey l indemnify
ti p q(W 'g t mJ fy dkeep ..L.7 ICI') fCu,rta
g InCity s' m a ma n cdg d the a I c h' Y any way cc against said
B b fl is �
► ArPItfFM- ' vTISNANSAND _L SMPLYWTT LL ON-POINT Issued by. n 2 jl�.�Ce� Dale
I, p,I ant/C.ntrvn.r _ _ — nae Re—rool's
I IAZARDOUS.MAT SDISCLOSURE
Will the
applicantpiof mtureWildWilding o.Cihpanr'tsan9n.1zw,abmnntJ'hlec hIalcznaNl'houu,nJnoStavf^n°yI Type of Roof
a.duOnedseCrIpplomIMunicip.lCo
,ale,smtdiotzrs53zm>a
_
OSef All roofs shall be inspected prior to any roofing material-being installed.
`. Will the appheamorfuture Wilding MCLinan'use equipment ordevices which If a roof is installed without first obtainingan inspection, 1 agree to remove
ani'hnmrsl m,eircortmainann n,,ddelated by the Us,Area Air Quality Malagcntent P g
ni,trilly uN. all rte materials for insp n. Applicant understands and will comply with
p ' t sour, a 'ons.
1 has real the havnlme,Inaenals yu;m'tmnts under Chapter fi 95 of e
el Safety CW e,Sedio s 05•.5533 and 25534.1 unJetsLanJ ha
ifthe lil IS nut mnrrmnly htnc c. ',Ihm it i,mY I*tmmililytn.o'if he
oc"i nI d't r circa one moan a and prior t ntc of a Cenitkei.
Dec 1 t r Signature of Applican to
Data AI oaf coverings to be Class"B" or bet er
OFFICE