01010122 CITYCUPFRTNNo
BoILDINPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PI!RMI"T NO.
1.0388 LFMDAI—C AV EUX'.E.-F FtJ.AaIBJ:NG 01.010122
OWNER'S NAME. APPLICATION SUB DAI'B
Fir-u:ESI-I GLPTA i.'.86GX-j RfAsIGI/.E: ST 01✓ 0/W. H
• PHONE: SANITARY NO. CDNI'ROL NO.
' (:':1.1.0)30.:3...:7�}!�7
M z% ARCHI I'ECTIENGINEHIR: BUILDING PERMIT INTO
O O 1{hllG FLEC1PLUMB ME 11
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C u u u u
u?j hICENSEII CONTRACTOR'S DECLARATION Job Description
Z L 1 M1crchy u0inn that I ant licensed under provisions of Chader t)(commencing
Ff—ed wlliSection](aNpafLvision:,nl'ma lfuvinessandl'ndes,ioa,Codc,'mdnry l lccnsc
m inn force and effect. fifF4AC E W6d'IE_R HU)TER
C Q Littnsc Class S D p
3 a D Dale Conuucaor .
G ARCHITECI"S DECLANAecord
t�O 5 1 fmdcml:nfA my Plans shall M mild as public records /
i
at
p
0 p Licensed I'mfcs,ional 3 /
l3WNEH�BU1LIlER DECLARATION
txe=w 1 hemby affirm Ilial 1 our excnpu I"mal the Con,mclor's Liccnw Law for the /
IF z S following rtasnn.(Scetion 7031.5.Bmines,and Prires,iom Code:Any city in county
I which t pernat toa t II p demolish,or rep' y structure
prior' t, drance.ifloo dc,mra,facippli,mit l hocmal to role ''g dill nen _
Inst he is licensed pt to the imerve.ions ofn Contractor's L Law(Chapter 1) Sy. Ft. Floor Area Valuation
Ir,,,,,.II fig wdl Seen...I70on of D'..on 3ofthe Bd,m,,,and 1rote,.on,Code) ?>`iC!1C1
,it that he i,cxcnml therel tom and he basis to,the alleged emmplion.Any violminu
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
or m,t'oa,ra)ban' We[I I...dodm,05(0), APN Number Occupancy Type
❑1.its owner of ma pope",m my employee,with wages a,their vale comlomntinn. :3C.,`7ti30(%J 7.C '
will do the work, mal nae stricture is not im,7,Jed or offered for sale(Sea 7044, Required Inspections
Buvme,s and Profev,ioes Crde:The Gmtmetor',Liame Law doe,not apply m,air 9 p
ow r of prolan Who huilds or impmvev thereon,and who Joys such work himwlf 5@2 — I-l:h(AL F'LUI'Q':t;L'NG QJE3iYiY
int rough hi,awn employ,,,pdivided thin such immmven,m,are not'upended or
offew Rat .It.If.Involve,the building or improvement is nom within one year mf 506, -- (DF)S TIEBT '
completion,the ow'nealaime will have the Maden of moving that he did pill build or
yna clirpnrmn, a,f,de.h _ '307 FIbrL FUM11140
❑I,as owner of the Iloilo ant exclusively contracting with licensed contractors to
msfruut the leojecl(See 7044.Business and PmL,,jum Cade:)nna Contmatmt,
License Law dons not apply to an owner of properly who Wilds or reprices therenn.
and who contracts for such projects with a contract (a)licensed"mem to life ,
Canlraclnr's Le,en'.haw.
❑1 in ammpt under Sec. .B&la C for this ream,
Owner Lane
WORKER'S COMPENSATION DECLARATION
• 1 hereby all!....under penally II'NO"'y
one of tbo....dowing declarations:
❑ 1 have and will maintain a Certificate of Conwnt m wi-iroum for Worker's
Compensation, ;is provided I... by Section 37100 of 'Lac I,;It Core, for the
perfonaece of the work for which this pemfit i,issued,
❑I have and will meintain W..it,, Cnmpunwtion msurmco,as required by Seat
37M of he IaMr CWc,for he pedormadee of the work for which this penal,is
wed.My Wrrkds Cmnpemation houranee carrier and Policy number are:
Cartier, Policy No,:
CIiRTIFICAI'ION OF EXEMI'I'ION FROM WORKERS'
COMPENSATION INSURANCE
frhiv section need not he emgduted If the Iarmil is for ane hundred dollar,
is 100)or fan.)
I anity'h;n in the perlumnard e W the work lir which this pemfit is Issued,1
shall mil employ any person in any manner ms v,la became subject m the Worker,
Cmdamotticn Laws of Celifomir.Dam
APmllc:ml
NOTICE TO APPLICANT:11:tarter making this Ccnificme of Useo I.You should
Msubject to the Worker's Confpemation provisions of the Labor Ede,you roust
Oenme 1nnhwi0, I Iply oil, net, novedon,tar fail Perot!',hull be deaned revoked.
^ 'n CONSTRUCTION LENDING AGENCY
a `�^ 1 heavy afro'Oen Cham I,;,c fium'Iran familiar,agency for the mun'otmaaee
of the work for which this permit in issued(See.3197.Civ.C.)
gl. Q lander',Name
047. z IcnJc''.,AJmc„
Q O 1 cenify the,I have read this applicmion and ,at,d o mr,atone infonnnism is
;to. [^r correct.I agree m comply whir all city and coa my on1'uumac,:rid,tate law,retailing '
V to Wilding considelion.and hero amhnriee r,Tasentaives offhiscily in enter uPam
the atone-mentioned Posen for inspection pacto
Fy per„ (Wel agree in wiveindcnmily and teal)hdnlas,lire City of CuprntinuaguinM
7m liabilities.judgments,costs and npunms which may in any wry accord against,aid
City in consequence ill the grinning of this permit.
^ APPLICAN',UNDERS'TANDSAND WILL COMPLY Wim ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. Y'
Sgnamrc of ArphceWCommmor Data Re-roofs
HAl RDOUS MATERIALS DISCLOSURE
so the applicant or future Wilding occopam store of handle hazardous matudxl Type of Roof
to.defined by me Carolina,Morrimpal Code.Chapter 0.12,and the Health and safety
Cade,Siltation 25532(ay2
C1 Y., 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building aacupatn use coirntent or device,which If a roof is installed without first obtaining an inspection, I agree to remove
emit hvaMon%air ennmminants a%defined by the Buy Arco Air Quality Management
Di'vicc all new materials for inspection. Applicant understands and will comply with
Lyes 0N all non-point source regulations.
1 have dead the hvmdar,mamdah regn'mmem wrier Chap,,0.95 of the
C9ifomia Health&Safcsy Cade.Sections 25505.25533 and 25534.1 understand that
it he I Iff of d m,nm currenlly boor,it onion.that h i,mY respon,ihidity'u truly the
occupied of the realuircmcnl,which must be trial prior m Issuance of a cedilica,ill'
Occupancy' Signature of Applicant' Date
Owner of dmhorvcd agent [late All roof coverings to he Class "B" or better
OFFICE