06010088 OF
ctBUILDING DIIVIISSIIONNO PERMIT CONTRACTOR'INFORMATION
BUILDING ADDRESS: PERMIT N0.
06010088
OpM18 SAME:PENDERGAST AVE PERMT4 EpATE
SANITARY N L NO.
ARCHITECTS GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i p LICENSED CONTRACTOR'S DECLARATION
0
r C 1 hemhy M.Nal I em licemod under previsions of Chapter 9(commencints {'per a rl til
wih Section le)of Divi.ion3of NC Business and Professions Code,and license is ■ ���®
M in full fora andd effect.
Z— LicamClaa Lic.is DEMO (E) HOUSE t
:a DateCammetor
ARCHfIECI'S DECLARATION p + Q
a 1 understand my plans shall W used a public reemds MAY 8!' 2006
U
i� Licensed Professional '
n3
OWNER-BUILDER DECLARATION ����®'e_��■r
_ rv�
P 1 herthy affirm that 1 em exempt from the Commesor's License law for the
0 o following reason.(Section 11n L5,Business m0 Profcssioa Code:Any city or county
IC! which Output.a Permits.anstruct.after.improve.dire.]W,m repair say strucum
:y prim In its issuance.also requires the applicant forsuch permit to File a signed statement
< that he is licensed pursuant m dte Pmvisioa of the Contrmmr.lineae Law(chapter 9 Sq.Ft.Floor Area Valuati
$ (commencing with Section 7000)of Division 3 of the Business and Professions Collor
that he u exempt teaefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects dtdepplicant to a civil Penalty of j.j b r Occupancy
not marc man five hundred dollars(5500} 0 0 p y Ty�
❑1,as owner of the property,en my employees with wags u their sole compensation.
will da the wade and me.wctum is not intended or offered fmale(See.]Ods.Business
and Prores.ian.Code:The Contractors Lt..Law doe nm appy to an m.,er of Required Inspections
property who Wildsorimprows themon,end who duessuchwork himselfor through his
own employcaed m
,provided such immre nnt
pm eents eimeaded m offered foraale.IL
liowevu,the building or improvement is mid within mte,yar of eomplesion.the cwv cr-
builder will have the burden of proving that he did at Wild or improve for purpose or
ale.).
❑1,a owner of the property,em exclusively convecting with licensed contactors to
construct the project(Sec.90".Business and Professions Cade:)The Convectors Li-
cense law does not apply In an owner of property who Wilds or improves hemon,no
who convects for such projects with aantnctor(s)licensed pursuant to the Communes
Lt..law.
❑I em exempt under Sec. ,B&PCT Ni.human
owner SLID HRRSHWN kwnAtz Data D- 161w
WORKERS COMPENSATION D I;ARATION
1 hereby spirit under penalty of perjury one of the following declarations:
CJ I hsw and will maintain a CantOve of Covent toselr-iasum for WorkersCompcn-
asion,a provided for by Section 3700 of the labor Code,for the par ormana of he
work for which his permit is issued.
❑1 haus and will maintain Workces Compensation Insurance as required by Section
3900 of the Labor Code,for he Performance or he work for which this permit is issued.
My Workers Compevelion Insurance carer and Policy number are:
Crosier: Policy No.:
CER71FICATF OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(7lTkseetia need not W completed trust permit isferone hundred dollars(5100)
car less.)
1 unify that to the performance of the work rot which this permit is lamed,1 shell not
employanypermn inaymanngg,ry{/mh/}g�s��.tin/pp Is, C subject to the Workers'Compensation
Laws Or Calirn.'ii Da C23laW ALa
Applicant ss4,�jy9 s2s vtd Gr1WK
NOTICE TO APPLICANT:If,afwr making this Ceniricae of Eacmptien,you Mould
become subject m he Workers Compensation pmvisiovof On,sabre Cock,you must
z forthwith comply with Inch pmvisina or his permit shall be doomed revoked. ,
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is•eonsvuctinn lending agency rm do performena or
the work fm which this permit is issued(Sts.3041.Civ,C.)
Lenders Name '
z Linder'.Add.
0 1 cenify that 1 haw mad his application and sue that he above information is
F correct 1 agree to comply with all city and county ordinances and sue laws rattling he
J building construction,and hereby mthortn rcpracnmives or this city to enter upon he
eMve-mentioned pmpcny for inspection purposes.
4, (We)Agree to saw,indemnify and kap harmless the City of Cupentno against
fA Inbilitics.judgments costs and expenses which may in my way see=against midCity
Z A mm"PLICA nee ofhe UNDERSTANDS
Shis Permit S /
^ APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Dale C!Y C
SsCEREGU NS.
t O-31&106,
Re-roofs
ShgnuurtorApplicaVComncmr pats '
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will thc applicant or future building Occupant sore or handle moodous man rim
as dcfincd by he Culo vino Municipal Code,Chapter 9.12.and IW Health and Safety
Cute,Section 25532(.)7
❑Yea ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applies.,or rot..building can mate If a roof is installed without first obtaining an inspection,I agree to remove
pP s w equivr Qu or divans which g P g
DBvily udnus air contaminants u dcfincd by the Bay Ara Air Quality Management all new materials for inspection.
❑Yes ON.
1 have mad the Weardas materials requirements undm0mpmr695 of the Califor-
it.Ou h&Stoll,hawc,Secdoa bar
I,I,m 33 spt 2553,y to mmf cad that if the Wilting
doe Out ems why hew a cant het tit is my rip?a.iceni to notify ft mcupnt of the
tigr rtmen_ts onery�y the met rwissu an cint0am or co Signature of Applicant Date
Owner or nthorircd agent Date All roof coverings to be Class hB"or better