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BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
1.
Ulbr� Vic% uta f�i^ 11p�f�i--� Ont , 117e.
quo Ma►►� �t.�Oz�
LICENSED CONTRACTOR'S DECLARATION
I hereby xRrm dom I am licensed under provisions of Church 9
wind S.rion ]000)of Divii11on3oftheBminess end Prof 'arm Cade, en
in full fwe end .Boer. /I. Q /n �%. %gf.C_ 7''j
' ARCHITECTS DECLARATION
I understood my plans shell M used as public sands 4'J
Licensed Prof selmul
OWNER -BUILDER DECLARATION
I hereby affirm that I as exempt from the Conlramfs License law for the
following reason. (Section 9031.5. Business end Professions Code: My city or county
which mquues a permit as concoct, niter. improve, denrwlish, m mpur guy awcnue
prima its i .... ace, atm rtgnims Iia spplicant for such permit On file. sig 1 nnemem
that he,, licensed pumuon m the provisions of Ne Contractor. License Law (Clamear 9
(commencing withS.tion 700D)af Division 3 of Ohs Business nod Pmfeoimu Cade) or
IMI he is rxempt therefrom end 011e bods for the alleged exemptian. Any violation of
Section 9031.5 by any endorsed fm a permit subjects the -Wheat he a civil penalty 9f
not mom Nan Eve hundred dollars (35001.
1. as owner of the propery, or my employ., with we,. an their .1 ....... due.
will nd 1M work, aodthe 6lrmtum is ata intcededwoRemd fm We(Sa. 70.4, BoYlnese
and limitations Code: The Commamor's License law does hot apply to a owner of
Fmprny who Wilda or improves thereon, xnd who derr such work himself or though
his own employers, provided that such morem menet art one sounded or ofcmd for
sale. If, however, the building or improvement Is sold within one yeerof completion, the
..builder will No. the burden fpaid., that he did an Wild or impose fm Far-
in.
mpose of We.).
1, as owoes of the PropedY, em eorluaively contracting with licensed Co... to
...... the project IS.. 71)14, Bull. and Professions Codr:) M Conbemora lice
can. law dos mol apply m art ower of property who Wildn or imposes thereoq end
wed convects fm such Mi.0 white conbxctunn) licenad puma nt to Ne Ci nlrectora
License Law.
❑ 1 am ascmpl under Sec. . B & P C for Nis moon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aRrm undo penalty of p jury one of the following delaratiom:
1 Mve end will malnWn a Cwigmm of Conserv mself-insure rot Wmker'a Compn-
ation, es provided for by Seton 3700 of the Labor Code, fm the prfomhance of Ne
which this prmit is issued.
sum Mve need will maintain Workers Cousy nutlon Imoence. as reco u ed by Section
3700 of thc LOW, Code, for the performeno of the work for which this pormil In issued.
My Work.{ Ilwrlmpryh5-e csria and Policy rets' .2/
Certiee �% -nIL///VU Policy No.: i���
Pq
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need no N, completed if thc yemon is forme hundred dollars (S10(1)
or hear.)
I.rify deal in the prfumounce of the work for which this pernit is issued. I shall
nm employ any person in any menno,. o to become subjal m dm WorkaR Compen-
sation laws of Cmifhmla. Dam
Applicant
NOTICE TO APPLICANT: If, .her molting rids Certificate of Eamption. you should
hewnrs, subject to the Workers Compenation provisions of 1M Labor Cade, yen most
forthwith comply with such provisions or this permit shell be domed mvoked.
CONSTRUCTION LENDING AGENCY
Q I hereby inn dot than i,econxtrucdon lending agency for th.pMmmohce of
y
to work fm which this Frsmi, is issued (Se. 3097, Civ. C.)
Lmdrea Name
FK > fenders Address
fy Q 1 certify IMO I hove mad this application ad fInc IMI the above information is
0. swat. I agree to comply with ell city nd county ordinances std gum laws miming to
building comstmetion, and hereby action. oc restrandoes of this city m ense, upon the
�! C above-mentioned property for imspctiom purposes.
Ls Fv, (We) agree to ave, indemnify ad kap harmleas the City of Colander, .gamut
U liabilities, judgments, costs and expnua which may in any way scene against said City
Gx7in cot ctucec of the floating of Nis permit.
t� d APPI.ICAN NDER51'AN , NII WILL COMPLY WITH ALL NON WENT
U BDUR� : UTATII/ZS
Sigmmuoof VCommnor I Done
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding ncciinuu em a or handle Mndous material
an defined by the Cupnino Municipal Code, Chapter 9.12, and the Hoskin and Safety
Code, Seta. 255320e1P /
❑ Yes Dig
Will the applicant or future Wilding occupnnt use equipment or devices which
an it bnuNous au mise mimnu as defined by the Day Arte Ar Quality Management
District? /
❑ Pos E54.
I Mve mad the Marcos, mawials issimm meat. undef Choler 695 of the Cali-
fands Heslth & Safety Code. Sections 255()5. 25533 and 2553x. l understood that if do
Wilding dcun;Zl ca mount, that it is my crism,bilk, minmfii(.fy the oci,xiiountt
of de usl be ern piss lar usuamc ofsCwhic.�Omais llL
Owers a8enlus.
00030017
FE
Job Description
wj/"r ll�gfier '&1V1'oee1? 171
Sq. FL Floor Area
nspections
3 ,'41
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source re ulations.
,;fl ZSR
Signature of V Vant Date
All roof coverings to be Class "B" or better
OFFICE