00110059 cf BUILDINGOFVSUSIIONN�
DIVISION -PERMIT CONTRACTOR INFORMATION:
BUILDING On, GREENWOOD CT CROWN ROOFING INC PERMIT NO.Ot ta059
OWNER'S�AMI8f _ APPLICAI'11L� SU )ATB
IF _ 214 CRISTICH LN gNt.:,/20tZi0
PHONE: (41D8) 369-7444 SANITARY NO. CONTROL NO.
OO ARCHITECOENOINEER'. BUILDING PERMIT INTO
BLDG ELECTPLUMB MCC"
Z S = LICENSED CONTRACTOR'S DECLARATION Job Description
Q a C 1 h rcM1y Imam th t I I rcwd J p f Chapter 9 bum ane ng ,
with Section n]fXNll of D t t n J f N Iii and Pr fewi - ode.via y hcenec
�3g Be, +- [y/Q/ j INSTALL TRMF'R00 FELT.
O 5—' CI I M tRrt£� `j —'r
tos' D,M1 ���'� ANL 111(Cn DTC r '
Sec 3 1 undemmnd my plansshall be axed p Is
d }
y E:O O La:ensed Professinnel /01
e OWNER-BUILDER DECLARATION
I hereby affirm that l am exempt from,he Contractor's License Law for the
C Z a following rcnnn.(S<edml)0315.Ilumm,s and Professions Code:Any city nr county
F F p wh ch y n pint 1 t , t Ila ln� e d , linh lu any amctnm ,. ,
63F$ pr 1 1 :' L ,ey :th I II histoi;l t g d:lt<nc,l '
that he T with
,. u de p :, of C tar r 1 La orwC '9 Sq. FL Floor Area
(ennme ' 8 NStrumofD' is ,l ofNeBa nes„dse Urw( hCode)
or That he is cxctnpl therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a Want subjects the applicant to a civil peri
of not am had Eve buolled dollars(S5(gm. y APN Numbbe�r Occupancy Type '
°L Its owner of he rt.'arm employees with wa esas their.sole core 3691 44[62. 00
pd the
Y6 compensation,
will da the work and the ode 'I lie
is not intended I Lie o0bnal for sale(Sec. In an gg
laxness pand en,r..innxcede',Tni Comm acre LicenseLawd,.sunmapplym," 303 — FRAMEequired Inspections
amer nrh him oiy WI builds nr in,nnrves Nereus,and ,coneren such work n ed I,
el Through nix own employees. building
;oat such tem n t is slid
arc nal..year
or 307 — INSULATION
coned for sale.If,noterms,iumilde,will
building nr improvement n sold within nae year of
iampini for the parom ofbadder w;o bi�,<o,<Im,den arpro.mg that nit dm rota build a, 60t — ROOF TEAR OFF
mvto,'e area parry,w.,r salol.
°I.axaw.ernfthcfndlgt,.ame,emslvel, emareliall with licensed eenhncmmto 608 — ROOF PLYWOOD NAIL
conamel the project(Sec.AHJ,Business and Profess inn,Code:I The Ctamm�or's
Licensee LiEw demi n a:y,na
ly to ,owner efpmpeny whit builds or improves thenen, 603 — ROOF BATTENS
.ad who cataractsMfor x.,h fai with a ormi limned p.,,a..(m de 604' — ROOF I IV—PROGP.ESS
Com ons License Law'.
01 am exempt under Sec .B&P C for Nis mason
Owa<r Dae .
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of Perjury one of the following declare,ions:. e .
0 1'oave and will Inalnmin a Ccroleale of Coroem to se16incure for Worker's
Compensation, as provided for by Section GIX) of the LuMr.Code, for the '
performance of the work for whichthin pend,iS I...did.
°1 have and will maintain Worker's Cumpenu,ien I......c.as required by Section
37M of,he Ldaa Ede•for the performance of the work for which this permit is
issued.My Worker's Com•p/ensa•�tio�n/In�smmnce carrier andPolicynumber are:
C.iricr 4 ye plt1 1<r Nu.:N�OM _
d I PIG [ON Of•P�%Eh1 PrlO I W k"IikS'
COMPENSATION INSURANCE
(This section need not M completed if the permit is for one hundred dollars
100)or lec,.t
1 cenify Nut in the perforaame of the weak for which Nis permit is issued.I
shall not employ any p<non in any annual So as to laconic subject to the Workers'
Compce'alion Laws of Cali fundu Dam nit
Applicant
NOTICE To APPLICANT.If,after,taking this Certificate of hxemption,you should
zbecome subjectin the Worker',Compen.sidam provisions of the"him code.you must
0 fonnwilh comply with wch provisions or his permit snail be deemed resnlrJ.
Fy CONSTRUCTION LENDING AGENCY
I hereby anon that there is a couxuu cion lending agency for the peafnmunce
W
,if he work for each this permit lx it,md(Sec.3097,ON.C.) t
L (�
Leader',Nome -
z L ender',A Idrcn
V 1 certify that 1 have read this application and state that he above information is
❑, F. correct.1 agree to comply with all city'anal county ordinances and State laws,elating
V to building ennstmniun,and hereby umhorim miumomaives ofthi,ck,p.,nmrupm
W the undue-meminnN prapeny for impte ion purposes.
L (We)agree in cave,indemnity and keep hannlev foe Cityof Culmina again,,
V] liabiCity in es,pdgmams,ether and e,penxes which maY in any wary necnm against NEI Ed, ��
U City in CANT U D of the graining of this permit.
APPL CO
SOURCE REGULATIONSNDS AND WIhI.COMPLY WITH ALL NON-POINT Issued by: Da
Signature ol'Apphcam/Ceamcter [)am Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE
Will Neannlicall or future building occupamstore or handle h:e:Wous material Type of Roof
as defined by the Coperino Municipal Code,Chapar9.12.and the Health and Safely
Ede,Seaton 25532(.)?
❑vex El No All roofs shall be ins cted prior to any roofing material.being installed.
Will the app0canlorfuture baddingohapiatameyaipmal,ordevice,which If a w
roof is install ' out f obtai in an inspection, I agree to remove
emit handed I,air conmmin.mx ah defined ny Ne Bay Area Air Gualityhlanagement g P g
District, all new mated to nspe ion. A icant understands and will comply with
°Ye °N" all non-point o e reg ation
1 amid read the nuallous mamrints requirements under Chapter 6I of the
Cmle bull nag hos infely Cade.atetinnu 255(15,t it is and^_5574.1 UYderYmnvflat,[
it the udecal of
does nnnvrenay h h ,,a,,be e,prior my ssuannsihilit to natif'Nc
cupam of,hc rcyuire cn,x xhich mart he ren prior,o Issuance of a Cenificu¢nl'
Occupancy.
tare of ApplicV Date
D.deror amheri,ed.gear Dae All roof coverings to be Class "B"or better
OFFICE