01010123 CITY OF cunitTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU[LD]NO ADDRESS: PERMIT NO.
1043 NOVEMBER DR fh 1 1714 123
OWNER'S NAME APPLICATION SUB DATE.
/P01711
IONS SANITARY NO. CONTROL NO.
OM->p ARCIII'I'CCT/ENGINEIiR: BUILDING PERMIT INFO
11I.D I:I.FCI' PLUMB MECH
r i G I -I IJ
<y
f-Z_ lima irvsFIDCnNnsedund R'Suliion,IiAr10N Job Description
Oo>: 1 M1ercby aRmh 1hm 1 am licensed under previsions'nl Chapter Y(commencing
F4Fa• with Section](XgBof Division 34the Business and Professions Qala and myucenee
is in all brave mW effect.
c�a I.ieen.e Cmx. Lie.x SOLAR PANEL ONLY
Date Comm.,.,.
ARC I ITECr'S DECLARATION
C O g I understand my plans shall M1e used its public record%
�z Z5 a Licensed Professional
,ce
Oat I and corapsih hear
tt11ARA'nf1N
w o m I hereby,(bent on I um.Imine Iron the Coban,Co I:Any c Law fur the
F Z� which firfloviincuires a pSection]UJLS.Business imp l,ii,demolish,
e o li h,or re repair
city or cnunry
whish it,i...a race,alk a camnnet.altco imfmne,Jmnn al,or ea'ir any enecnm
de.hoslcensed al.mn1.he lheappliemtlory anducniuolilnssigned Haipse,9
— thatheislice withScmnnothepmnmonsnllhftheBueinessarnmLawrnhCerY Sy. Ft. Floor Area Valuation
(commencing with Section]in and DivixienF of the Businow and I'c. ny i Code)
nr hunt he Is cnunpl here in and the huai%for Ibc allugcJ oxcngninn.Any violmfon
of Section 703I.5 by any applicant for a record nubjcen the upplicanl to a civil penally
of net mea man Five hundred dollars($500).
APN Number, Occupant p
❑I.n aI',he pn,penoy, my enpluyce with wage%as their soli,co,nlxnxalan.
rill Jo the work,and the sImcttrc is not intended or offered for.sale(See.BILL J s_
Business ant]professions Coll Br,Contractor%Licence Lax'does not apply to an Aqutred Inspections
iwvacr mpm"',ly Who build.or Imp,ovus t heree c.:,mI vino dun Inch work nimxen'
or through his own employees.provided that such improvcnmml are not incaded or
offered for sale.IL however,the building or Improvement is cold within one year of 304 — ROUGH ELECTRICAL
mhplolion,the owncrvhuildcr will have the burden of proving that he did nn;mild or
'mpoorbapnrpe,enfl,le.l. 501. — FINAL ELECTRICAL_ ENERGY
e•� the propeny,ant exclusively enmmeningwimlicensed rnntmemrlro 505 — FINAL ELECTRICAL
n,orncl it,pmjea(So,,9044.❑ucinos.and Pont,"in,is Code:)'rne Commnnrly
Licenm Iaw Jces not apply loan owner et property who build or intpmvev thereon.
and who hiarnnnmtrar.,for such projects with a comxprlsl licensed punm to the _
Cnntroco's uc Lnw.
❑IDI"�j.}� Pl nnJcrS c, .B No I'Cli,nhis nuam
Iwn`1 •. �eep_Dme 4—Z3-U
// V(11tK1?R'$L'OMI'I:NSA'l1UN IJECLANA'I'IUN
1 hereby affirm under penalty of perjury one of the following declarations: G/
j 1 have and will annular, a Cerlilic,cle of Consent m I'lLlnxurc for Work','I o
Compensation, az provide) Por by Section 39W or he LaMe Gods, for the /
perf screace tie the work tin which this permit is issued.
01 have and will laicism Wanlair'%Conhpenvnion lnsmmrim.as required by Section
3700 of the laher Code.for the performance of the work for which chic Warcul is
Let].My Worker's Cmnpc,v;niun Inenr:mce carrierand P11111v numhcr,r.:
Carrie' Puli,e No,
CERf11:[CATION OF EXEMPT[ON FROM WORKERS'
COMVENSAfION INSURANCE
[Ibis section need not he completed if the Noun is for one hundred dollars
1$II111)("lr".)
1 feniiv that in the perli,nnance of the work for which phis permit is issued,1
such not employ any person in any incliner so as to bseome subject 10 the Worker,
Co„gxmnliun L:tw.v of Cant 1,r Duce
Applicant ^
Nf yl'ICE TO APPLICANT:It:uBer making lhix C'enibcule nr Esnnpliun,you sM1nuld
G hecn ...Fier,to the Wurkcr's Cbmpuncnton Pao .0 attic the Labor Code.You nett
Q Q fonbwith nmtply whh vmb pnrvicionn u,',LiY permit.M1ull he deenaJ revoked.
z N CONSTRUCTION LENDING AGENCY
5I hereby alrimh,nm antro is a emw
sninha In eirtg,yency for Ise perrnrnm
, ee
of flue work far xhiel this(emit is issued(See.30AD.Civ.C.)
0. A Lender's Name
.7. z Leader'[Address
`.) C
Ii,,1 fy that I h' J eh.applicationhN o 1 th t the Minformation's
I,. [�. Corr 11agree 1 ,plyp a Y J ty I' [state laws r upng
Q (� fob IJ b ,lh ' of Id, ',YI t oo h Q
i the M e I I ponnthY y f inspection
u ptI
r, (%'JS
Z (We)agreemxacc.macnmyand whih.rmlesx theC1yof Cupcnnoaguins
.c V] City in et,judgments,fonts:vol Starting
of hex which may In mry wary acttuu hguinxt ward
CilyincANTU D Rhus NESA DoticpernO
APPLICANT UNDER \NUSANO WILL COMPLY WITH ALL NON POINT Issued b Oe- �ti7J rV L/C C,f DLIC f-/Zr2J1
SU'2C1!NI:GUI '.
�A 4?3til
,,antes nr,\vpreGtcnmmen,— . Balt] Re-roofs
11AZA lanum MATERIALS t since OSURE
Will yt epphexna m lanum ipal Co Code,
share or handle naeardouh Safely Type of Roof
as defined by the 32(d)!no Municipal Cole,Chapter 9.12,and Ibc Heultlt and Safely
Code.Scclion 255R(v)'!
O Yex ,aNa All roofs shall he inspected prior to any roofing material being installed.
Will the applic:mtur IalumiuilJing occupant ew eq optical or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
•mit hazardnuc air eonmminanu as donned by the Buy Arca Air Quality Management
idn,rr all new materials for inspection. Applicant understands and will comply with
O Yes /10 No all non-point source regulations.
I have read the ha/Cana.materials mquiremenl%and,,Chracr 6.95 or the
i_ __
nin Iicom,&Sufcty Code,Sort ^_55115,25511 and 25534.1 i n fe,'s,anl phot
uilding Jces not currently hose a mnam,thus is N my responsibility co nolifY the
m.,I he mrrviaments which mu.1 Ire ren prior n,issuance of a Cenircme of
°ii,y. Signature of Applicant Date
y-Z-3=C21 All roof coverings to be Class "B” or better
ornu ,gem One
OFFICE