00090149 CITY
ofcDPv RON)
NPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS:. c^ PL'RMITNO,
kuTe2:t the c5oGuT/oAZ -Z;C.
OWNER'SNANE1466 HOLLY - APPLICATION Bt)H DA'I'li _
�.. PFHONE. BURNELL LESI_ A SANITARY NO. - r c t h
S.tN use CA %S 11 Z
n wO z ARCHITECT/ENGINEER: RUILUINC I'GRMI'I INFO
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❑❑ .D ELECT PLUMB ,MFCH
LICENSED CONTRAC 1 Ok S DECLARATION
$S c 1 hefeby mi.m W t 1 1 e...d f v .. ns orcn p, 9 as narrating Job Description
t-ys-w
with Section 9000)of M1 ftheff - dPofc ,Co udmylcense Q
YO a is,.fall force and di
c34 ilea }/03 _ SHANE TO
ase Cplas �iLW
s �r Dale t jAska__ Conaaaor .. S _ _
ar c m I ARCHITECT'S DECIA TION-
5Ct5'=°g 1 anac.�h,nd any pan„nail be usee:,s a trT s Cb A E x� W��5�'4ke-ROO
.wmc LicensedP f .ianal �- c . . r i
OWNER-BUIL ILn} FCLARATION, Z-J JQV' �c(:/1'`+s '8'. f/e At/,V sy�}kE't
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w o I he br' fir lo-t 1 np r 1h c ,mc, . � Lo,w sort he - �'L LQ• CAtP1`ree
Z 6 fold g .(Sect 703 I.5 Business a d P l ions Conde:Any city or county, -
which requires o permit to construct,alter,improve,dm inh,or repair any orucmm
;ay CCesprior to its issuance,also q s the applicant fsuch pe "u file a signed suattracit SOF
m 3 that he islicensed pursuant top ,. It Contractors License La (Chapter 9 S Ft.Tecta:Area Valuation
(m mn g ithSect 7000) fD' l fineB a adP t .Cade) u'or that he exempt therefrom and the basis for the alleged exemption.Any v'olafo n
of Section 7031.5 by any applicant for a pencil subjects the applicant to a civd penult -
ofnot..tare than Rve bnadred dollars($500). y APN Number __ - - Occup n
❑I,as owner of the property.art my employees wilb wages ax Wel....Is campensatian.
will do the work,and the'mature Is not intended or offered I.r.ale(Sec.7041, �201�
Bit ass and Prefcssians Code:The Camara License Law does not apd,rct an 2 e .�s R� ired Inspections -
orvr of property Who builds art i;nthereon,acid who docs such nark himself ,
,hmugh his own employees.providedidcd,that such inspnrvennena ere not intended m -
offered r r sale.If,however,the building or improvement is sold within one year of 305 — FRAME
'completion,the owner-builder will have sloe hwJea of proving that he did not build or -
imvmvefor Purpose orsale.). .307 — 1NSLII_AT70hl .
°Las owner of the property,am exclusively contracting with licensed comrea,aos m 601 — ROOF TEAR OFF
Liconstruct(lie project(see.7044,Business'and Professions Code:)The Contractor',
cense Law does not apply to an owner of property who..rims atimpmves thereon. 602 — ROOF PI_.YWOCID NAIL
.and who antracts far s,,an mejoits with a clai mam(s)licensed p.,.an,,o the E03 ROOF BATTENS
Conmmin License Law.
❑lain exctpptu,nee sen. .B&Perar this reason '604 — ROOF IN'—PROGRESS
awnc. Dam - .
W'ORKER'S COMPENSAnON DECLARATION -
I hereby affirm ander pcnuay of perjury one of the following dmlarmians: ,/
❑ 1 have and will,haturnin a Cartificate of Consent t If' fm Worker's
Compensation.am' i p k df d for by
Section t'.17!s0ued f h' L
b
Code, f 'W
e Q/2
®
1he d will m W k :Cooperation 1 . q days to
3 10 [lie CuJfih performance1 the work f which this pert..,is
,"seaCa �YInsurance and policy yhMk ' p
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c-0. PaaayNo.: 1d.4 ea8 i
CERTIFICATION OF EKEMPOON FROM WORKERS' -
COMPENSATION INSURANCE _
(This secfon need not be completed it the permit is for one hundred dollars
IS I00)or leas.)
1 ocrod"hu,""he Derfmanarme aG the work for which this permll is issued.1
shall not employ any person in any manner m us to become,subject,o the Workers' '
Compensation I-r—of California.Dam
Applicant _
NOTICE'fO APPLICANT:If,aBennuking this Cerifcme of Est mptioq you should
Q 0 become subjecta)the Worker's Compensation previsions of Labor Code,you mus,
6rthwal,amply wain mth previsiunn or this mora shall be deemed revoked.
z Fy
.F h CONSTRUCTION LENDING AGENCY - -
I hereby far wo,h this them is a nmsd(Sec. lending agency for ten pedbmmnee., _
Gail of Lead work me which,his permit Is issued(Sec.3097,Civ.C) '
(,Z Lender's Name
Ixnder's Address -
CIcertity that l have mod this application mndstate that above infornna,ion is
W Fy turner,l agree rn amply with ail city and county ordinances and,ante laws relisting '
V to building mn ninar n,and he,chy auWmi,c repmnanmtives of this AYn,enter upon - -
'y r� ,he abovo-mentioned pm,rly far ioepm,ion purposes.,
Q,t (We)agree to save indemnify and keep nurmless the Cityof Cothran.against
h' linbt . j Agm,yyt t d paints which may In any -y against said
City' q 6c of th g , '¢-- t
APPLIC ER P, WITH ALL NO DINT Issued by: Date
Ireate u, 9 ossa
S
, Avvaeannc t t D:, Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ,
Weapplicant orfuture building�,ccola,nt,storeorhandle hannaboushater;al TYpe•ofRoof the cupemno Municipal code.clnalna 9.1 z,and the Health and Safety
Code,Swion 25532(o)7
- ❑vasI N° I r All roofs sha I Pbe.i n spected prior to any rooting material being installed.
Wtu he appImantormmrebWldingoccupantuse equipment ordo,menwlddi ,
train h....d un aircemiminnes,an defined bythe Be,Area Air Quality Mannge,nem If a roof is installed without first obtaining an inspection, 1 agree to remove
ois,aee - all new ma rials for inspection.-Applicant understands and will comply with
El Ys ° "'r all non- 1 source re al
1 have read,he hara.dous mamrialn requirements under Chapter 695 sof the _
Colliernia Heal &Sal'cty Code,Sections 25505,25533 and 25534.1 andecsmnd that
If the buildsggyyy, s es no,curcntly havn,e ;, n i,'n myre, to if 11 + 7
accupm� IILCtRCI p rto issuance ofa mllclna f -
9 S ature-of Applicant` Date
0 rornotherizedogent All roof coverings to be Class"B” or better