01090110 CIBUILDING DSIONO
IVIISINPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
7505 RAINBOW DR JONES MASONRY 01090110
OWNER'S NAME: APPLICATION SUB DATE
KIM 1058 DELL AVE 09/25/2001
a .PHONE: SANITARY NO. CONTROL NO,
4083777512
GW O 7p ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF,CH
r,u
LICENSED CONTRACTOR'S DECLARATION
5 w z 1 hemb (fine thm I am licensed tinier f Chapter 9(cummco6ri Job Descri tion
iZ—O Ya Prov Pameo P B
r whhsecBan7Bomarumiamn3nnheBusiness and Preaamnacme.and mybttn CHIMNEY REPAIR FROM G OiJND.
is in ull forte and crt ssII
i O W u M.,fClass L2"s Lie.0 q o?
Da¢ Co lrr nl 4
3 u ri, ARCHITECTS DECLARATION
n 0 g 1 understand my plans shall he used as public records
i r
7 c o O Licensee Professional
OWNER BUILDER DECLARATION
1 herby affirm that 1 am exempt from the Conwctai s License Law be the
t?a following reason (Section 7031.5,Business and Professions Cade:Any city or county
2=A which rearme,a Permit to cons $4200
truct,alaimprove,demolish.impve,demolish,or repair any structure
a3� —0-It
issuance,also hes the. listen for such lm file.signed aatemem
(comm cingwit pSection7th!pit Diiisinr Ne Ce Business
Licencelaw(OwlRcr)
r a, Valuation
trommeerisewiresecean7fna)drhe baron3ofeaBnslmummnot eros.sten) t'f,Til� �l3����.tQ�•it.1 T;S, f !.('`+
or m.i he n exempt Nerermm and the bates.for the anege9 dempdod,any vmmtmn f
of m nrcmanlove
v n 70314 oany applicant for a Pmrit subjects the applicmt to a civil penury
orhot nlmenunarcaannar.(aSBm 101p`PNl0i�t)ATION Occupancy Type
❑I,as ownv or the progeny,ur my employees with wages ss their sole compensation,
will do the work,and the swetute is not intended or offered fm sale IS=.70414,
Business and Professions Code:The Contractor's License Law does not apply to an 514 — FINAL PMdIt1Yr@d WIQRK13tns'
owner of progeny Who builds ter improves therm.,and who env such wink Mmmlf t
or Through his awn however, Provided that such vement mems are not intended or
-cHercd for sale.If,ho builde w l Wilding or improvement of Prov n sold within one year of -
vian,the owner-builJer will have the burden of proving that he did not Wile or /
improve1asneer ofthe
.. ❑1:as owner of the Progeny,am exclusively d Professions
ns licensed contractors Contractor's m ,
Licenconsumuse
the does
project face Ito a,Busowner of and arty who
Codep The Condictio, 1�
and who
ca does not apply to an owner or progeny who builds seimproves t a the < O
and who contains for such WalamI with a comrstor(s)licensed Wnuant to the
Contractor's Littnx Law.
❑tom exrmPt under tees. - � � :B&P C forthis rtmon .s'l" . ". •
_ - O.;. Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declaatiorev
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compemmmn, as provided for by Section 37M of the Labm Code, far the
perfits cep of IW-work far.vhich this permit is issued.
s1 have and will maimI. or the Pe Compensation a work(r hick thi by Section
oared of y Worker C«I n for the Performance to the work which this garters is
issued MY Wordcrr;Compc t insurance.rear and Policy number arc:
cgrrm r `LmC 511 0 �.\ , 5 1 Policy N W C l R O 13 I l 4 0 m
i" CE FlCATION OF EXEMPTION FKOM WORKERS t- '_i-s S Ys .f. i•' t� .
COMPENSATION INSURANCE
(TTis section ncN am be completed if the permit is far one hundned dollen
(SIBBI«leu)
_-
'I certify Nm in the pvformantt sof be work far which this permit is issued.l •.
shall not employ any persm n in any manner so as ns come suhPn,rude Workrn'
Compensation laws ofCabfbrdia.Hale, i�—ref i
Applicant
NOTICE TO APP LIC ANT:is Compensation
this Citrons fof Labor iode.y Mould "
becomeh comply
the such
Compensation Provisionsof the Labor Code,you must
Z 0 foMwiN cote ply wit.such provisions or this p<mtit shall b<dttmcd revoked.
F CONSTRUCTION LENDING AGENCY,
I hereby uHie m that there ika emiswctimi lending agency for the performance
of the work for which this permit is issued(Sec.3092 Civ.C.) -
QLender's Name' . . ' - ' .. � .
0.' Lender's Address'
U"C> I unify thatted l have sethis application end Itme the the above infasmetion is
W Fa comet:I agree to comply with all city and county ordinances and state laws relating
Da f,,,) to Wilding construction:and hereby aurhorim representatives of this city to enter upon
_ Ne.Wee-mentioned prepeny for in.apection puryases.
,
0. (wej ogee m save,indemnify and kap hornless the City of Copertma ag.irm
W liabilities,judgments,costs and expenses which my,n any way accrue against said
ULZ City in consequence of the granting of this permit.
r SOURCEAPPLICANT UUNDpER�fSTANDS'ANDWILL COMPLY WITH ALL NON-POINT Issued by: Date
SignomwillTdme pepplHAZARDtmc Wilding11.1161
O •,
Date Re-roofs
"
RIALS DISCLOSURE -
' - occupant roue«Hanel hirardws rrmuvnl Type of Roof
d f d e. io Ne Cu«n M ni pal C Ch pt 9.13,a d th Neallh etM SaPory
I
cm' ov.,z553zO rl ; a. .,i � '.,°, ' � ` S !'ti \art '{';p,t�er ; ,• t'',. ; .i.
- All.roofs shall be•inspected.prior.to any roofing material being installed. ..
Win he aPprraat ow to aipre a!ter aevicea which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air ci morrorin as dd by the Bay Arca Air Quality Management
e
District? - r all new materials for inspection. Applicant understand_s and will comply with
0Yca, No all non-point source regulations.
I hirii""I the lietmdous'materials re,mr mets under Chapter'i of the
California Health&Safety Code.Sections 25505,35533 and 35534.1 undersand Nat .
Here building does not currently have a tenant,that it is my responsibility to notify the
cupmii of the rtgoir cats which must be met prior to issuance of a Cenlficate of
_ °rvp""y 3 _ Signature of Applicant Date
d' l L All roof coverings to be Class "B"or better
«
_ Ownter mAhmind ager Date
- I OFFICE . . ..
17 „. 1 I .