01040066 CITYOFNGDIVISION
. PERMIT CONTRACTOR INFORMATION:
BUILDINO ADDWHSS; PERMIT NO.
20200l_UrTI 1h
OWNER'S NAME: APPLICAI ION SUB DAfH
PHONE: SAN]LARY NO. CONTROL NO.
?70
M ce O ARCHITLCT0.:NGINLIiR: BUILDING PERMIT INFO
W❑ BLDG HLIi -F PLUMB MP.CH
F]
<c
p S�_ LICENSED CONT RAC IO DECLARAI']ON Job Descri II 1
= I hereby alfinn Thal I am licensed under previsions of Chapter 9(commencing P
Peck IIIb S-bon]Ixn))of Division lot deo ljusine,,and protect ns Cod .and my l iccnsc
is Y i J is in full lime uv f(ct� yl�9_35G 11
3LLF umenw cll.,F l.im.« REMOVE SHAKES INSTALL 1/2 CDX
m aide_T2� cn�nrnnnr
ao nraclurea-sDEc1.ARArION X. 30 YR. CERTRINTEED SHINGLE.
(r—¢,g I understand my plan,shall he used as public records _
w —
y a pp LicemcJ IYokaional
d w o
OWNER-BUILDER ra the ORATION
to
I hcrcFy u0inn IhuI1 len exculpt Gam the Cnnvnnnr's Llccnsc Law lar the
fnlb,wing reason.(Section 7031.5.Bashes,and Pmdsvion,Cale:An,city nr county
Iia whicM1 requires.a permit It,consu ml.altar,imprme,demolish,or repair any wcure
to n,air m it,ssuance.also mquire,lhe apit cant fur sue'"our In ale a signed atatenmnt
L this,neis licensed puts..ntmmepaoikkart,anneContractor,LabbowLa. Chafer9 Sy. Ft. Floor Area Valuation
(commencing with Section 7aN))of Division t of the Business and Professions Code)
,,,,but he is exempt 11u,mrom and the bush no,the IJIcgW exentpdnn.Any—inion
of Section 7031.5 by......]i..,fur a permit subject,the applicant m a civil penally
ornalmorethan for hundred dodant55UB. APN Number Occupatwl&fpe00
❑I,as owner of the propcnx or my employers with wages as fheir.nle conatedo Ian.
will do dm work,and the sImorm is oat intended or onercl for sale(Sec.](U4'
Bnsina,and rmfesdmtx Cadt: the Common..Llcmuc Law,doe,ant apply in an - 31602094: Vel Inspections
teener f p open,Who build,,,, n . thenced. ad vilho car,such work h :If
or through .hn pl ) p Idtht h p r I eat intended �l
otered I - Ir 1 d n I I' g o p IJ 'd' a y d - ss
anmplt bu lJ Ili the bud lip rgthat b JJ Ibuild rt 305 — FRAME
�S//O
himouve for pptp )
01.a f he paper, I . sly urnown.,withI :il cordiatt to 307 — INSULATION
himnact the project(See.7614.Baancs,and larnfeswans Code:)Tee Courts, s, 601 — ROOF TEAR OFF
w La,does nol apply In un deme rl property who build,rr irn ante,.,conn,
and who cantracl.for wen prnjurs with a amtmcmgs)licensed pursuant m me 602 — ROOF PLYWOOD NAIL
Coun nous',Liccn,m Law.
❑Iant exemplunder Sri. .118oPCbr,ddxreason 603 — ROOF BATTENS
u,ncr Date 604 — ROOF IN—PROGRESS
. WORKIRS COMI'BNSA'I'ION DECLANA'I'ION
I hart by alfinn..ruler penally or pevinry one of he frllowing dedarminm,
• O I have and will maintain a Cenilicnm of Consent or self-irwre for W'orker's
Coniptusad t us providal rnr by Seminn 37(.) of the [..he, Cale, for the
perf smantee of the,talkfor which Ihis.moil is issued.
rand will muimuin Workcdx Con pavarin i Insunmcu,m required by Station
"'I of the labor Cotte,lin the pert ainance of the work for which this permit is
wed.My Workers Compeln^mion Insurance carrier and Policy run ber am:
rarricr.,f�kN[liC4.�—{�rift-11plilS'y No.: .
CERTIFICATION OP MEMPi'ION FROM WORKIRS'
COMPENSA'T'ION INSURANCE
(This Ovation recd nm be contploed it the permit is for one hundred dollars
(5IWI nr I'Sl.I
I trendy that In the performxnee of the work for which this pemrit i,issued.1
,hull nor employ any Terson in any moon.,so as In hcennn whjccl to Itic W"kers'
Compenvtion Laws of California.Date
Applicant
NO[ICH 10 APPLICANT It.uficr(nuking Ibis Ce"iticale or Excnlption,you shomd
nano.,object the Workers Cnmm
pcation provisions of the Labor Coale,you nos, -
Q C ., tt
Rothe i lin comply with such pmvisians or this parrot shall he termed ranked.
z
F' CONSere is a ON LENDING AGENCY
a 7 I hereby that mere iss issued i8 e. leading agency for the perrnam.nee
Ixn Fmk for which this peon[I is Issued(Sec.A19],Cie Q)
L Q lender's Name
Q 7 Lcndcr's AJArcss
V C) I certify that 1 Wive maul this application and afore that the above mb rdeinn is
W ,Cy contra,,I agree to cwnply with all city and wunly...durance,and nam laws retain,
Q U Io1bildin.con.wedun.and herebyanunire nposentmi...nl l'h locnter upon
the above-mentioned progeny for lrpcction pur.roae.
L (Woggrecmuave,Indemnify and keep M1unnlna the C'ny nl Cupeninu uguinxt
F^ In liabilities,judge ciat.coals and expcinws which tiny In any way antrum against said ,
C.) Z City in aonsaquence of the granting of this pc nit.
APPI.FCANT UNDERST[�ssh SANO WILI.COMPI.Y WITH ALLNjjj)N INT Issued by: .Date / V
SOUHC RGGULA'I'I y'
15%j
yrlawm nt npplirnnVCmnnml r )ate Re-roof
HAZARDOUS A AIS UISCLOSUR:
W ill the applicant a future .tog.,chant mac as harmle hmamou,material Typ Roof
Cv,dclincd by the Calx'Iim,Munmgnl Cock,Chapter 9.12.Itnd Iba Halm and Surety .
alc.Section 25532(.)?
0 Yes 0 N A 1 roofs shall be inspected prior to any roofing material being installed.
Will the appIkaderr mote hildingtccupnalua c,tipuwar trdavices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hazardous ler comominarn,as defined by the nay Area Air Quality Management
Dial<tl all new materials for inspection. Applicant understands and will comply with
. 0Y`a °N'n all non-point source regulations.
I nave tend the h:Inudous materials m,ulmmanns under Clrum,r 695 of the
Califnmia Health h Safety Cola Section,25505•25533 and 25534.1 understand that
ifbe haildingdnns not cuncndyhave a rental,that it is my responsibility to notify the
ccupamt of in,mca
u,which natal hm u Inca prior Insuenco of o CcniOuum of
txmapamy nature of Applicant Date
aumndzm agtrnl )J,,. A coverings to be Class "B"or better
OFFICE