01060076 CI HuOF
BUILDING tiONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21849 ND
OWNER'S NAME: APPLICATION SUB DATE
170
PHONE: SANITARY NO. CONTROL NO.
PANGRL
R90 2 ARCHITEC'i'IENGINEER: BUILDING PERMIT INFO
z C NL96ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Z 5 H Job Descri on
Oi@❑ Ihertby arm Hallam liccnsN under provisions of Chapter(commencing
r so wlM Sectiont )of Division Jof the Business and Profusions Code, ylicense
a x�-1 °mR rnreea - 3S� FOUNDATION REPAIR
c, Li se I Lie M
%3 LL D Dale L'O,II(aelnr .x!
[J ARCHITECT'S DECLAR ION
O 1 and nd,my plgos shall by ysed as public recordsce
//Q
p Licensed Phi fess nam
OWNER-BUILDER DECLARATION
I hereby aR,m that 1
C?F< exempt the ContmaLicense Law for the
ollowingaiosnn. ] 1. Buiness andum Coe:Any city or county
❑ Which q a permit In construct.after.imp
...
,demolish. r
repairtoy structure
6C�- P t t. �,Is q ' th pPl' I( tp rnoflicir,,,red,imeocianpwr9
II t o cn r6 with t thn"pr nh c 1 .Cc 1 (chCode) Se ,Ft Floor Aica, cation- -
a' c,cingwmbx.rgnmoanddue sisoo(meBwlesa ndirm.k ursende) f'; r";'. }'. tj t.aa•� t.?'F:1!'al.:�'ti, $550bd
or that he is esempl Ihercrmm and the per for to alleged amicant t.Any nolauan '
-o(Senion90J1.3 by any appliumfor a permit subjmm me applicant to civil penvlly ey�.7Im � -
.of not mom than five hundred dollars($50o). 365Rl8' h - Occupancy Type
❑%as owner of the propcny,or my employees with wages as their sole comprmattion,
will do the work,and the structure is not intended or affr,cd(or auto(Sec.]044,
(Businessand Professions Cale:The Cmirromr's License Law does not apply to an 101 - FOUNDAT I wired Inspections
owner of properly Who Wilds or improves Ihercon,and who does such work himself
.or through his awn employees.provided that such impmvemenn are not intended or -_-_ 10 2-- _PIERS ------ ----, -(_
...
ffcied far sale.1[A,iwever."the building or improvement is old within one yearof
completion.the ownerbuilder will have me W men of proving that be did not Wild or 1 3 - UFER `
improve for purpose of sale.).
_.. ... . . .Property.
------_... 104----REBAR . ..._._._.., --
- --
"m a owner of me progeny am Bmirt,,ex and contracting wlm licensed The Cmil oto m
iceme,
'heow pini«I Iappltoa,owner
anderty who b mod es Theves thereon. 105 — ANCHOR BOLTS I
and-who
Law tree not apply to an owner of property who builds seimproves thereon, i
.. and who eommens for.surh.pmjena.w¢h.a commcmrtU licenaee.pursuanuo the .... . ... 1.06 --- SEWER-.& -WAVER
Contractor's License law., '
❑lamexemptunder5ec. ' i B&PCforthisrewun 202 - UNDERFLOOR'1'PLUMBING
own=, Date 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECIARATION 204 - UNDERFLOOR FRAME
• Ihemny�mrmunderpenalty grpe;ju'goprufinemllowingdeclaraliow:
❑ 205 - UNDERFLOOR INSULATION
1 have and will maintain a Certificate of to self insure for Worker
Compensation, as provided for by section 3]00-of the Labor Code, for me 301 — ROUGH PLUMBING
pe nmmnreorrhewasfor.1 .h mit isirsq% 302 - TUB &-OR SHOWER
❑1 have and willinainrain Worker's Compensation Insurance,as required by Section 3 03 - ROUGH MECHANICAL
v I J I ,,,CATION OF XGM PTION FR M WORKERS, o perm a
37W of the labor Cod for the perfo m ce f Ih
edM'VorkrsCompestugMsu c Nom<rundPolcy
'number an: 304•-- ROUGH ELECTRICAL
4 work f which this
c c � I 305 'I:ERAME 'j< t {rl4
COMPENSATION INSURANCE:,,
y (This sL2 tom need not W comple d if the Permit is for one hundred dollars 307 - INSULATION
151001 or less? -
308" SHEETROCK
I rti(y main the pef am a rm work for Whichlh ,6mna isimed,i
Ish II t mpl y any pe o y mann r 5o as to become' hien to the workers' 309__ EXTERI OR�'L'ATH
Cmpensal on Laws a/Califom d Date' - -
.Applicant ... ... 310' -"--INTERIOR-"LATH---
NOTICE TO APPLICANT.If,after making this Cerfificam of Exemption,you Mould
act y '
Z -bceomrSubjacotheWorker'sCompensationpmvismnsoftheLlmrCode.youmust 311 - SCRATCH COAT
r. O With such proviAmrs o,chis Permit shall be deemed revoked.
- - _. — 313 -"-ROOF "HALL._.. .
forthwith comply
F Vl fin CONSTRUCTION LENDING AGGNCY' ^•
tooth Ihereby
kforWhichthl the i ar n, S leading aynryn m p,romtapre 501 FINAL ELECTRICAL ENERGY
pe .xu us .j . ,m- - - 502 FINAL "PLUMBING ENERGY - -
'� Q.... Londe sNdme :.. _. ,�,_ :. ,_. _ ...- ..-... -
Z Landers Address ` -
503 - FINAL MECHANICAL ENERGY
U O Ice ifyntatlhave rem lhmappricmfor;andwas,ha,tneai>ovemformatmni.. 504 - FINAL BUILDING ENERGY
'cmhcx,I agme to complgwith all city and county ordinances and stare laws relating
O U to buildingconswclion.and hereby authorise representatives of this city to enter upon 505 - FINAL ELECTRICAL
the aG m mo l ncd Immurty for inspeei o pop es. -
P.
(W-)agree to a e d mn ify and keep hmonless th Cly otC p nlno g imp
IiaRlile judrmm,costs and expenu inch may y cove against said 506 - GAS TEST
V City' consequence fthe g tingg of 11o,pant -
APPLIC NTIND 4NDSAN WILL COMPLY WITH LL N-P INT' Issue
07 F A L ING Date
. SO Er LA Op : Q 1 GEN _
Signalure App ,, mrmuc, "' , ate Re-ro(EfiD9 - FINAL GRADE
defined
❑Ya a cr ._ _ YPr 1 f- -FINAL PLANNING - ...- --... ... ......... ....
HAZARDOUS,MATERIALS DISCLOSURE f
Will th<oppl'cam or Tum b ,ld'ugac pant oma or handle h ratios ulenl Type O
by the C:perb o M s' pul,C d Ch pl 9.12 I m He hh and Safe[, ,
Codes Ion25532(a) tv 5 4 1i=..`•,FINAL' PUBliI'C,:WOI KS
b All Too s shall be inspected prior to.any,roo mg matenal.betng installed._
• W Il Ih applicant forum building bytes t equipment r tl vices which .. ..
cnthamN Ppican11 rant a Je(pngbympBay ArcAQ or Management
If a roof is installed without first obtaining an inspection; I'agree to'remove
'D ma gyp/ all new materials for inspection..,Applicant understands and will comply with
all non-polntsourceregulattons.
` vl have lead the h d u,mert" I. equi'h mems order Ciottie,6.95 of he
California Health&Safety Code'Sections 25505,25533 and 25534.1 understand that
lithe building docs not currently have a tenant,that it is my responsibility to notify the -
copam of the rcgyj mens which must be met prior m wsm a of a C nifscam of -
.1)ccupan
Signature of Applicant, _ Date .
own nr enl,
at, All roof coverings to be Class"B"or better
:':. '.,; . , '_ -,.�._ ' . : .. - ... ._ ,. .. . ,ar•-...- - -'OFFICE - -. . ..-.... .... .. . .... _. ., . - -- . ._... . .