00050042 ct of cuPe
BUILDING INFORMATION:
uun.oc DIVISION
su3ry PERMIT
BUILDING
., i'GRMII'N
OWNI3R'S, .. APPLICAI
AIM
1'HONF: SAN)POVY NO, CONTROL NO.
ARCiIi'fEC'1'/ENGIN'IiliR:
BUILDING PERMIT INFO
BLDG ELIiCIPLUMB A0iCH
F�6 C_1 1 171 I-1
a
y=
LICENSED CONT p .Wumol ChaN
•� QQ lneacnr.mrmtl,ntla,nheensed�nderprndannsarenapmrvnnmmenC1"g ADDITION Job Description
with Seatinn 7000)of Division 3 ofthe Hi vias and Professions Cute,and my license
ofin in full lira and effect, -
z Al< Liceme Chas, Lic.N
d C d U Care Conavae " -
'+�3 G ARCHII'ECr•S DECLARATION
C= 1 andemmnd my plan.shall lin t".1a,pnhhe(.canis
C Qi
n s 1,¢enseJ Professional /
OWNEIbRU1LDER DECLARATION f,/
ad e N 1 hereby affirm that 1 am exempt from the Contractor's Limn«Law for the
C Z ofativing reaana(Seed 7031.5.11 inch.and 11 Talion,Code Any city or county O
,�a which acquires a pandit or construct.after.improve,demolish,or repair any structure
a5m priu In Its lsnunnce,alw nyuirex;he appllead lar ruck pennint fid a signed.uatemeen
dant he is hanwal former,to the proloons of the Contractor's LiameUnits(Chapter S Sq. Ft. Floor Area fr
baron eraing with Sad inn 7yKb of Division 3 of the Busine—sal Professions COR) ,
or that he is exempt Sembilan and the basis I'or me alleged uaigmor.Any ululation
of Section TO 1.5 by any applicant fora permit subjects the applicanno a civil Penalty
of a I;mire man live hundma dnEa,.($500). AT..NEIMillb$r9. 00 Occupancy Type
01,its t r of the pmpany.or my employ sail with wages as thei r sole compensation,
will do the work,and the structure is not intended or ollcmJ for sale(Sea Il044.
Business and Pmfessltns Cat e:no Contractor,License Law does not apply to an 101 — FOUNPAJFdrQN nspect ions
r or prop,oy Wht.buildsorin,pn,vnx daemon.mod who does sash wank himved 102 -- PIERS '
or through his awn employe political that such impnnements am not intended or
aBmed for sale.1f,bnwavar,the hnading or i)nprovement is sold within one year of 103 — UFE R
completion.the owner-builder will have the burden of proving that he did not build or
improve for putpownfslle.) 1.04 — REBAR '
01,as owner of he Prop.ny,am exclusively a,mmating with licensed eomreemr.m 105 — ANCHOR BOLTS
mgmm Ne Pmlect(Sec.7044.Business and Prol'eo;ons CuJe:)'rhe Contractor's
u«no,Lawdee.nnt apply to anow„erofumpeny who mild.,imp....,domain. 1.0E — SEWER tG WATER
and who contracts for such pn,Jecis with it comracono licensed pomiata to the
Carmelites License law. 2202 — UNDERFLOOR PLUMBING -
711 am exempt under Sec. H,C P C for this mason
203 — UNDERFLOOR MECHANICAL
Owner [)ate
WORKER'S CONIVENS ''10CLARATION 204 — UNDERFLOOR FRAME
I hereby affirm,mder Penalty of perlary tine o ern . agdemaradons: 205 — UNDERFLOOR INSULATION
0 1 have and will maintain.Certirente nr Consent m Is am for Worker's 301 — ROUGH PLUMBING
Cnntpcamdon, as provided boli I,y seaam, 5700 •���fff-���LLLhe Ia or CoJr. for m.
pertem,anannlRwmkn,rwmanmi,permitI,issuce. \ 302 —'TUB & OR SHOWER
01 have and will mainmin Worker',Companmtion hammoce,as required by Seddon 303 — ROUGH MECHANICAL
- 3700 of the Labor Code,for the performance of the work for which this Permit is 304 — ROUGH ELECTRICAL
,sued.My Wade,,Conal....last.......varier and Policy maths(ore:
rte,: PnlieyNo: 305 — FRAME
CERTIFICATION OF E%IiMPI'[ON FROM WORKERS' 306 — HO DOWNS
COMPENSAI ION INSURANCE ¢t I"1 LIl
(Thissenon need not be a a datethe peri
on,ifit is beeline hundred dullan 307 — INSULATION
($10(dold".) 309 — SHEETROCK
1 caddy that in the perrom,ana.ohne work bar whieh ode III is issued,I 309 — EXTERIOR LATH
shall not employ any Pemtm in any.....nor eo as I)hero..subject a,the Workers'
Co;npe..ratim,Law"ofCalimmia,He's 31.0 — INTERIOR LATH
Applicant
NOTICE 10 APPIJCAN'1':If.after making this Certificate of Exemption.you should 31.1 — SCRATCH COAT
hecnme object mtLe Wei kcrh Compensation ar ,ism ofthe Lahor Oahe,Ynu ust
O ZO fai ib empty wire such provision,or this perout hall rte deemed revoked. �r 313 — ROOF NAIL
F ^ CONSTNUCHONLENDI,NGAGENCY 501 — FINAL ELECTRICAL ENERGY
1 hereby whims that;hem is m anted(Seen 1091 C e.C.) for the perG,rnanm —
onnewarknowhiahmis raitisisoree(seavrn.civ...) 502 FINAL PLUMBING ENERGY
a z ic�der Add,
O ,, 503 — FINAL MECHANICAL ENERGY
Ianify;nate,avereadthisapplic;tion and said that the above information is 504 — FINAL BUILDING ENERGY
se. attract.I agree ,,aomphy with all say and county odarames and ,are law,relating
O U mnundingctmstraction,andhemlyattmurimreprcomarve.ofthiscitytoenternlam 505 — FINAL ELECTRICAL
d,a.base.tnemioaedp„,,.yfor inspathmparpams. 506 — GAS TEST
F y (we)agree tome.indemnify and keep harmless the City of Cufaminnagainst
Z ,multi,,,judgments,cost,and nxpeme.,hen mar in any way calla.;tidiest said 507 — FINAL I_ B I NG
U i City in consequence of the granting of this permit.
APPLIICBNF.GULARSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SVIR — FTNAI M NANTPj;i I_. Date �
Si,redenlAppllc;o;lCo,1.act,o - O,,,a Re-root's 509 — FINAL GRADE
Eli RDOUS MNI ERIALS DISCLOSURE 1.0 — FINAL PLANNING
Will doe apphicamor future mdldlng(lament stem or hantna himmax,nmenal Type of Roo
as defined by me caumino Municipal Code,Chapter 9.13.sad the Heald,sad Safcty 514 — FINAL PUBLIC WORKS
Coate.Section 25531f.rf
DYes C1No All roofs shall be inspected prior to any roofing material being installed.
Will fee n"fliando,halite,banking oaapama,eegnipment(it da,i,x% hi,h If a roof is.installed without first obtaining an inspection, I agree to remove
nd,hazardous air contaminants as donned by me Bay Area Air Quality Management
nistdm all new materials for inspection. Applicant understands and will comply with
0Yes 0 N all non-point source regulations.
I have rand doe hionolne,matan.b mganententr nnticr Cmpmr 0,95'If doe
Coli6mi.Health K Safety Cole,Sections 25505,35533 and 25534.1 understand that -
iI It,bit!ding dare nm cuncndy have a coma.that it is no,ov,din hi lily m Iran fy the
occupant of the requimarms which matt be met prior to issuance of a Cenifieme of
O atiettey, Signature of Applicant Date
Care,oreaminuea again Dam All roof coverings to be Class `B”or better