02020023 CITY
BUILLDI C DIaVISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21153 PATRIOT WY WATER HEATERS ONLY p 02020023
CHLTNIM NAME
970 E. MAIN ST, SUITE 20 AbPy�lcj 0 Nfll kY2
PHONE: (415) 566-2209 SANITARY NO. CONTROL NO.
❑reZARCHITECT/ENGINEER: BUILDING PERMIT INFO
L02
Ow BLDG ELECT PLUMB MECH
:J fJ L__l 1.:7
LICENSED CONT'RACTOR'S DECLARATION
Z z y z 1 hereby firm that 1 am licensed under f Chat 9(commencin lob D Crl Lion
o —o provisions ver e REPLACE WATER HRFRrp
p Hs_w w;m Section nxwnalavisinn Sonne eaan<as and Prnf<..aona a>ae.ana ter h«n.x
r ei ;a in Tau force ana f�
°'O w D Dmc Contra an
u�3a ��4� r
O ARCHITECTS DECLIO
ARAT
S I understand my plans shall W uud az public records ��� 2002
w O O Licensed Pmfcssinmal
a n o OWNER-BUILDER DECLARATION
='m rm 1 hereby affithat I am exempt from the Contractor's License law for the
Gfollowing reason.(Section 7031.5.Business and Pmfe,ions Caie:Any city or county, L.DING $700
which requires a permit to construct,alter,improve,demolish,or repair any structure
a3� paota its ssumree.d q the aPPlb tf suchpe tin fileasigned statamcm. nqi A - ._...--.--
Natnslcen. dpursuant mthe pvisiosofthe Committees License Law(Chapter 9 y. 3.vC.n� ��.a�aty,,1 Yc ; Valuation
(commencing, im,Scci t,70BO) fONi91on 3 or the Business and Professions Code) n`.4„}.'h i. . ,x-01 l di
or that he is exempt dohs ram and the basis for the alleged cennptiDo.Any violation
of Sm6on903L5 by any applicant fora permit subjects the applicant to a civil,malty
of no,mars,than B«hundred danar,(S5nm. 502APN]NqqftL PLUMBIN ENERGYOccupancy Type
°I,as owner ofine propenY,so my employees with wages as mar sole compensation, 506 — GAS TEST
-will do the work,and-dr,'swcture is not intended or afered for sale(Sec:70L1r'
'ausin<sa-and Professions Cadet The Contractor's License Law does not apply m an 507 — -FINAL PI9RPJrJhTFnlspections
owner of progeny Who Wilds or improves thereon,and who docs such work himself
or through his own employees. buildin that such improvements mems are not intended or ._._..,._- -_____-,__�_,;_--___,_. _- __
completion st a owner
Wilder
w building or urden fprov n sola within one ycv of i;: - - .
completion,me Dwner W it.).will have the burden of proving thin he did not build or
improve(or purpose of sale.).
_. .._ .._ _. . .
D 1,as�wnerann�
proper Y.ten exclusively d Professions
with licensee C.a,.t to
construct the project(Sec.7t1N,Busowner of and early who
CW e:)Toe improves
thereon •1`. it
License Law aces not apply man owner of a contr woo Wlice or d.pmvn thereon. . . .
C .ena,wctorhiv a License
Law.ch Projeda with ocnmmnnr(s)Iiccnscd.Pursmnt to she-
Contractor
he. . . ..... .............. ..... __.._._..._.. ._.. ... .... _. _.. _ .._. .__. _...... ._._............_. .___.___.. .
_ 01 annescr Licenselaw.
❑lam exempt unacr See: �� •� � � ��9&PCrrn this reason ice ' 'i`rl't.
own nate' .. .
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pcnalty,or Perjury one of the following declarations:-
0 1 have and will'mammin a Cedi(cae of Contend to sdLineme far Worgsr's
Compensation, as,provided for by Section 37W of the Tabor CeAc.-far the
performance of the work for which 0is pc crit is issued. ,
¢!have and will maintain Worker's Compamisation Insurance,as cal by Section
W of the Labor Code,for the Perfo ce of the work for which this parrah is
assucJ My Wo c mo Inou an c 'nnJP I<y ni tuber at
C;""-"t /Pclicy No2-
CERTIFICATION OF EXEMPTION PROM WORKERS i �. i t�,AC. . l;i.. J .t t
COMPENSATION INSURANCE `
I
Wcompleted if the permit is for one hundred dollars
1'cemfythat int-he n inaiiyn atrthe orkfr h;hm ct l' sork.em .V tt
shall oatalic.L any person m dry to as m Wwmi subject m the Workers '
Comficant ipn Laws of Ca1;lornia.Date
T.
er
ng
ata
n.
ould
Nstnt chjc&.,he Wi it It.Ctimmascumin o6vibi n,of of Labor orot.you i hors,
Wrnmeh comply
the such
eCisions this pn.i ion.sil thefavor Code,you mon
Q O fonhHim comply with inch provisions or this pcmniuhall be dam<d revoked.
CONS TRUCTION LENDING AGENCY
gC ' 1 hereby aBimi that then i.a'conswction lending agency for the performance ("
W..4 of be work for which this permit is issued(Sec.3097,Civ.C.)
.Q Lcndcr's Nome -. ..,.... .........- _.. s. . . .. ...:...... ... .. ._ ...._....._ ... ._ __ . ._.. _..... _ .
as Lender's Addre>a :'. .. -
Z.7 O Iccnity that i have read this application andsmre that the above information is
colocit.1.1.to comply with all city and county ordinances and state laws relating
to buildingeonstiunion:end hereby iulhodurcprescnwti.es birdlik city to eme,upon
} LT7 the bot ned pro,cocy for inspect purposes.
, .. . .
Es-d (Wa);.9 cIt, . aliaennify and keep harmlass the City o c.,ronoall.mit /
(A liab 1 t s/ dg netts costs
.t. and expense both may in any ay ac c.,most said
L,1 Z C'ty a conx9 cc of the& t ng ooh n
APPLICANT UNDERStANDS��DW�'�,p�OMFL' NITH ALL NONh/IT ' issued by: r` Date
SOURCE REGULATIONS: _ (/QZ. y:
Signature of.Appllcam/Comracmr " " - ate' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE a
Will
applicant or future Wilding p t storer handlebareadoustet al __Type of Roof.
m defined y Cucrfino Municipal Code.Chapter r9.12. old the Health said Safety
Code,Section 255 (.1 . 'It"
Il
Ya beiinspected prior to any.roofing
,
._ ._.
material being installed _
•
Will the applicantD r his Wilding Paul useeq v t or de,ice.whin If a roof is installed without first.blaming an inspectiori,'bagree to remove
toii,M1 I eir chi 1 ,defined by the Bay AreAir Quality Management
D a et all new materials for inspection.-Applicant understands and will comply with
t ❑Y. I" _ all non-point'source regulations; -
.. 1 hale read the haz.rJons materials requirements under Chaplet 6.95 of the
California Health St Safety Code Sections 25505,25533 and 25531.1 understand Nat
ifthe,building dues not currently have tenant.that it is my responsibility to notify theoccupant (the r qu h¢h intit Wancap or to'i - cola nil pati(
°c p'` �� Signature of Applicant_ _ Date _
owner cosoared serration, Dar, All roof coverings to be Class "B" or better:., "
OFFICE
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