02020021 CI TY GDIVISION
IPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20151 NORTHWOOD DR WATER HEATERS ONLY s} 02020021
09��0&' MORTIMER 970 E. MAIN ST, SUITE 20 A011c/06/20bE2
PHONE: (415) 566-2209 SANITARY NO. CONTROL NO.
q p ZO ARCHITECTIENGINEER: BUILDING PERMIT INFO
ap BLDG ELECT PLUMB MECH
tF6d
Z O y i LICENSED CONTRACTOR'S DECLARATION Job Description
pz_o Ihereby n7000)rmmmlamhceneBusinunder
sandPronsofChapter sCord, nd(comy sense REPLACE WATER HEATER.
PHF-uJ
with Section7000) fDivixionlof jM1e Business and Professions Code.end my license
is in full force send fcg
z a License l fs Lic.M37 $ 7
O w U Dmc Conhactur
uO r" ARCHITECT'S DECLARAT N
g I realm and my plans shall be used as public records
w i t-O Licensed Professional
c W e OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Com....M*s License Law for the
I_' $700
'O O
Za following mman.(Section 7031.5.Business NM Pmfe,,,mns Code:Any city or county,
8 P O which me,ims a Permit to construct,alter,improve,demolish,or repair any smuctum
ce
a 3 prior m its issuance,al u9 rm s the applicant for such peno file signed gned statement �,.s qs�s�I e -
thathaafirenudptrowifdIDeprovid.m.ftheCon tncm. Lcen.eUO,(Chapter 9 f 1C...3CIsr.CNA�aqY 11 . Valuation
(commenting whh S«u n 70D15)of Division 3 of the Business d Professions Code) ),1`� s s. f it:4 a J.f'♦\'.1°1•Z f E f_1;
or jhai he n exempt jhcufmm and jM1e basis for the alleged exemgloa.Any violvmon
—of Section
tsubjece he uplkam mncvil Penalty
ofnmmore than five hundred dollars s500). SO2 APIVgQ!l)XL PLUMBIN ENERGYOccuPaneY Type
❑LmMvmcroftnepm«r$armYemployee,with wages as mine sole elite«naaeam. 506 - GAS TEST _
-will doth k'and the Wase is'not intended or'offered for sale(Sec 70,$4,-
Business a
014 owners. nil on. Code The Contractor L d« t apply t 507 FINAL PI) rFb1(yspections
ow of property Who import
ah d who
d h .k himself �Y
or through h ow rty employees.bre pI yee provided jM1 j such improvements are not intended o
off d'f Ie If th 6 Id g d
completion.theowner-builder will have thebe v bfp g that he did notit IJ or
improve far p ryox of a.1.1,
❑I as Owner o(jeep ec tY Is ly Imli with lie J j n s toI � �
Li W t the eats no(S 7Wa B .n d e Profession,Cod r)Th C stat , I I
License . d«s not apply m an owner of property who Wilds r improves thereon.
th
_and who Com acts 4osuch Prmlects with a.crmracmrts) licensed pursuant w the .. _. ...__ ._. ........ .-._..-_ -_ .... _._ _.._—...... ..._._ .._ ._..
Cot n License Low. T\
0 Pj rWcr Sccl 'B&PCT this reason 'Qh
Owner
"Dam -
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of P2rjury one of the following declarations:—
❑ 1 have and will maintain a CwHicaie of Consent to self-insure far Worker's
Compensation:as-provided for by Section 37M of the Labor Code. for the
performance'of the work for which this permit is issued,
l Jhave5nd will maintain WVmkcr's Cme,emmum Iniurnice,as required by Section
'of the'Labor'Code.for'thc performance of the work-q for which this parprot is
C My
_CZeeFICATION�U'iEXEMPNo,
0 F�RiOMPWOR�RS+a/�. .. _.._,_F,,_._._...___. ___......�_..,._... . _..a_..e. x......_.....,_...__..
,76!f 1 o rr } i. „l,
N r•• ..' tit
'. .a COMI tiNSA'TION INSURANCE) ° Y .__--
`r Tb. r n need not be completed if the pe.I,I,foe one hundred dollars '-I' ' tl1' --__ —_•- ••r I. ' l,t'.. ? H
( IIl01 or �
cv
' T c nidi that m the n'in tiny mare it ort for rowhich N pinto t rc issued.I , - I; ! z r ,. l,t�t`• ' .I
shall not employ any fCalif'm any nmannd m as to become subject in the Workers
C P . tion Lows 1 C 11 ziv.Date,Appl -
NO17 Cant . .. . .
Ncame subject
ANTWorkers
after mak) gots Cm Team of Labor Code,you
•^• -
hceomeh ..t ,Md Wankel.Cin.o,or Mi,provisionsofthe Labor Cmle,you muse
Z — forth_'int cote Midi such provisions m this pcmrit shall be JcemcJ r<vokeJ.
I her CONSTRUCTION is a ON ructioLENDING AGENCY"" ' f'
I hereh firm jnm them tis cimed(So. 3097th for the performance
afffic mfin', amwhich this Pcmrit is issued(Sin.JfN7,Civ.C.)
Lender's Name. .''._..-..• __._ _ _ .: .r. .. i...,_' n_ r.._ ._. . .
d' Lenders Address
f..l'C lcenify that I have read this application and state that the above information is
kc E. carica.Iagrce to comply with all city and county pNinan«,and stem laws relating
Qo(J mbuilding connmctiorlmd hereby authorize representatives of thik city m enter upon
the b j ned P P ny f nspe p p s
f y' (W)agreeta ave.ihdcmnify and keep h psi the Ci Ly f Cuperineaganst
z, Ii b I i Cs judgments c tand experses whichexpense may in any way against said Q
f) Cjy r . q it fth g rt gof thisP I ._
APPI.ICANTUNDER$rANDS' LCONS WITH ALL G 1 T
SOURCEREGULATIONS /d Issued by: D to
Signawa'af APplicanVCo moan '•' Re-roofs '
v HAZARDOUS MATERIALS DISCLOSURE
'][,he ppli_... efwm bul.J.... p ttoremhmNl<harallous mat ...Type of Roof---.-.-.
�a dein J by th Cupea n M n CpidC J Chaps 9.17 d the Health and Safe, r 1 , tt _ r,
Cm
S uon 25532(x) ".lt a Irl t a .!1 r i n •)•s. s<' y. .i'C lebM t.l�ri n�i AI
_ , a ,All roofs shall be-inspected.pnor.to any roofing tnaterial being nstalled..
• wpm ppl t t t - n ldi s occupant e equipment o a v« which, If a roof is installed without first obtaining an'inspectron, I'agree to remove
e th d air c r ms as def dby tireByArcA Qml'iy Mang cm'
District? all new materials for inspection. Applicant understands and will comply with
n
`all non-point source regulatios,
.. 1 have ad he M1emodcasromenials re,mremenumule,Chapter 6.95 of the
California Health 9 Safety Cole.Sections 25505.8533 and 35534.1 undersand that
,if of tng he
es m,m tcurren Mlov/Jm�yya It be Men it iso responsibilitymnodhthe
Occupant ni f the rcgmrc en •—'b Prior.m s e ala Cenifca¢'If
C 6.,«
I .
_Signature of Applicant _ _ Date
Owner. amort: ,agent D /fie All roof coverings to be Class"B•' or better t,
._,,,.. .::. . _. : '. r,': . - -- OFFICE-