01120086 TY
' CI
BUILDING DrnSiONSINO
BUtPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS. PERMIT NO,
21591 GRAND AV CALIFORNIA SECURITY ROOF NG 01120086
OWNER'S NAME: APPLICATION SUB DATE -
PAT BROWN 90 UMBARGER RD 12/20/2001
PHONE: SANITARY NO, CONTROL NO.
(408) 363-6400
c Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
00
or— BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
5 L= under lob Description
OZ_ Ihercbyaffinnvasaw. icensedxmssrovisionsofChapSea.an myincing REMOVE EXISTING COMP. ROOF . INSTALL 30LB
F_F_; 'ith Section]0001 ofDivisionJof The BuxinasanJ Psofesxionz Code.and my liantt
is in full force and a t.
�o1u DCe"xecmxa x`39 Lic.«_�� INSTALL 40 YR CELOTEX COMP.
+q� Data /R- s DFCLAf
�++a.S'• ARCHITECT'S as public
N
S�y� 1 understand my plana shall be used m public rtcords �
w a<O Licensed Professional
o OWNER-BUILDER DECLARATION
1 hereby affirm that 1 a.1. exempt immune Cessions or's License Law for thefollow �C/
t:?awhichingmason.(Scis ine.momm.'5. iness and Professions deomh,.,reair Any city mascoure
Y r county
O which q perm n e n,aline improve,demolish,o pit y nrucmre
u°. coE 'hatpriowits issuance.also re to the movisio s o theforContractors
Permit License
signed aw(Cha mem'hat he etlicensed pSesaw win provisions Dis,,ka The the Paa°f L' Law(Chapter Coe) S1 FIt 4" j ea +� - anation
or Int c g. rapt n°narrian The ba moot thequn s' ini lesions Code) I Vis'+ 1 tl} 'y .` ( :e 2. 1t =, n. '.rz,. it
or that io is exempt therefrom unJ me avers for the allege]izempnion'Any l Pennon -
-of Secti°meth n iv any hundred Boli rota permit subjects me applicant to a civil Penalty
326
of not more man me hundred]colors Issooy. AFW lq_U1fi1YCr ,.. .. Occupancy Type
ID1,a.s owner of She property ur my employees with wages as their sole compensation, 2 Q 5 _
will do the work,"and-the structure is not Intended'or offered for sale(Sec.Y6L1,
Business and Professions Code:The Contmcwr's License Law does not apply to an 307 - INSULAT IR)Nuired Inspections
owner of property Who builds or improves thereon,and who d«s such work himself
or through h- n employees pro ided that such improvements arc not intended or 601 ROOF TEAR OFF
oB d'f' -I If;h' (the building or mpronment is sold within one year of -- - - - " -- � __ - — - — - - --- ---- --
compleuonmcownerbitlderwill have the huNenofpmvmgShsh<did not build ur 602 - ROOF PLYWOOD NAIL`'"` `
improve for purpose of sale.). 603 - ROOF BATTENS
❑1.ox owner o(she___. .__. __ _.. .-_. _ _.
ROOF
_ _ _
propeny.am Business
and Pmfa..,i.ox ods,i)Te Contricttora ROOF IN'-PROGRESS
License
ct aw proses Tapp.]loan Business and Professions ild%or improves
ves Contractor's
andw1b Law does con apply man owner th property who bmice se improves thereon,
and who.cm ions for such protects.with u commcmr(s).licensed pursuant to the _ ._..... _.... _._......._.._.._....__...-- .. .___....... ._
` B&PCforlhlsreuoo
FINAL
01 ex's License Law.
❑tom exempt Sa.' C
Owner . ...Dam .. ` . I�D
+ - WORKER'S CDMPENSA'r10N DECLARATION JAN tsI q q
Ihereby amrm under penalty of perjury one of the following declarations: JAN O 3 L0OL
s,�1 have and will mAinmin u'Cenificam al"Consent to self-insure for Worker's
C apemation, as,provided for by Scaian 3700 or the Labor Code, for the BUILDING
_ performance of Sh<work for which this permit isissued.,
- ❑1 have and will maintain Wbrker'i Compensailon Ihsum icb,as required by Section
37M�of me labor Code,for the performance bf lbe work fdr which this pe.sit is
orker's
issued.qar, 10ERTIFlCATION' PolMPI'IOlSFR061 cy num:xrarc
/� nJ P
C S iFa'CERTIFICATION
FEJU! PTI %37373—d/
WORKERS' i . s. ,. � t,'\...
'
COMPENSATION INSURANCE
(Thi tion nee]not he cnmplet d 1 the per ri t n for on<hundreJ dollen �s h' '' (' I I ( J ' -
(S I W)arlea)
no camfy,Shat th pct d e f rs fk for wore sub pet t s sske 1
shall not employ any pe on n any ma sops,w Ixrome ubjen m the Workers " ' 1• _ ''
r
Cnpton Lowsor I .I .m' "
Applicant ' 11
'M]TICE TO'APPLICANT:IL Comig iation sCenorn;o of Libuir Code.you ...
bccbmeh cont comply
it suchisCoions ortim pmvisi shall he
the Libor revok you roust
O Q Tonhwith copiply with'such provisions or this permit shall be deemed revoked.
r P:I•.:
I'CONSem is a c0NLENUING AGCged
.da > I hckor affirm this Shore tis issued(Sec.
lending agency for the performance i.t
.� of the work for which this permit is issued(Sec.709].Civ.C.) _
-LenJer's Name—
Lend'.
ame— -_ _._.:. ... .. _._......_.. ..... _ ...._. . ., . .. _ .
'Lenders Ayldlss
( tieemm1have edthis ity,application anyestmthatthedsat information aeon is
cones 1 agree to comply he all cay,anJ county ordinances and stain laws mlmin5
O Vw bmldmgconnrua on and hereby euro preventatives of this city to enter upon
>1 tt. gi th boa aimed property f inspection purpose J(
W' [we)agree Inaemlem,fy and keep City of Cuar°no otaim,
judgments,costs J expenseswhich y n any way accrue against.said
(j..z CiSYlln consegqta��e Ilce°f the gco smg of this permit.
APP,41C rD.NERSTANUS AND WILL COMPLY N'ITH ALLNON-PGINT '
sD•'>y ecucIssued by: Date
S e ire ofA,hrrm/Cnmmno - -
:t pn'e Re-roofs
HAZARDOUS NA DISCLOSURE
Will the PPlw rofumrebudding ace pant tortor handle blia"smaterial ._Type of Roof ...,�,..,......,... ...... .,.
as derided by the
OC pn Municipal CChpt9!)1{2. ad hIH, efland Safety
Code Section25512(xa z1 1' ..11 n L
I
hf 1A
mterial being installed.
Al . fi
Will the applicant or more hoildgoccupa[oney p devices which If a roof is installed without first obtaining an inspection I'agree to remove
smut haiard th contaminants as AeB b Ba Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
all❑bit poini'source regulations.
1 have rtati the hamrdous mate alt rt mrements under Chapter 6.95 of me
.Cal fomSa Health k Safety Code.Sections 25505.255]7 and 25534.1 understand that
ifinebu of t does not currently au"himamnam,ot'd is myresprasa oflirywnocry the' -
occup:mt of[h iremenlx xhich muss he not prior w issuance of a Certificate bf
Occuef or sumo
. .'' - ' '• ' ' ' Signature of Applicant Date
i•. - / ZOO ' . .._ --- --- - . .. _ . .__. ...
ri:ed agent' - • - Ome All roof coverings to be Class "B" or better
OFFICE.. . .._... . . . ..... ....- ..... .. .. _.. ... .. ._ _.... .... . ..