01030048 C1 tauhe DI SSIIONNO
tLPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22085 REGNART RD VIA BUILDERS 010030048
VB DATE
Dw�u);f{•S81E.& CHRIST HENRY 4600 EL CAMINO REAL A03c/T09ION 5/2001
PI(ONE:LV (650) 948-1077 SANITARY NO. CONTROL,NO.
D s Z ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
H O O BLDG ELECT PLUMB MECH
a U C1 1=J 1.=1 L. I
8Qa
S`,i LICENSED CONTRACTOR'S DECLARATION Job Description '
o z_0 1 nerenr affirm mat 1 am fiancee tinder Proviamn,urcnapmr 9(enmmrnd"g NEW SINGLE FAMILY
lin s-w with Section 7")of Division 3 of the Business and Professions Cale.and my license
i.,In fall force andeffµ;y C 12 318 7 S
�o�a License Class un.n 717 05 Q. FT. LIVING SPACE,
Date Araazf Cntmctnr_ 410 SQ. FT. GARAGE .
"�3 u Fi, x ARCHITECT'S DECLARA ON
LLO g l undersand my plans shall W used as public record.
f uvj to-
i S o O Licensed Professional
xo� OWNER-BUILDER DECLARATION NOVI hereby afRrm that I am eacmpt form the Contractors License Law for the N14 2002
1=z< following reason.(Section 1831.5,Business and Professions Code:Any city or county
E Z O which requircva permit to construct.alter,improve,demolish,or repair any structure
.prion.its iss ctami.alsorequims the applicant for such .am file a sigrmd wtemem - - -- - -
'hat he is licensed pursnimuo the provisions of the Contractors License Lav lChaptcr 9 Sq..Ft. FI DING - $s000 ation
(commencing with Seaton 781x1)of Division 3 ofthe Business and Professions Code) ., \
m that he is«cmptthctifrom aml the basis for the alleged exemption.Any violation -
-of scctinore me than by any applicant for v psoras subJe,'a Ne applicant to a civil pcnalry 3 3 6` I-b'Sunb9lo Occupancy Type
of not mthan five husbanddollars($50)).
❑1,as taw,net of the property,or my employees with wages as their wle compensation,
will do thewoa:and the structure i,not(mended or offered for..ale(Sec.TM4, 101 - FOUNDATId�dlLired Inspections '
Buiiirsks'and Professions Code:The Contmcmr's License Law does not apply to an `
o
rat property Who builds nr improves iherson,and who cines such work himself - 102 - PIERS
orr through his own employees.provided that such improvements is sol are not intended ye r or _ _ - _
._-6«ereA for sale.IL c,hmIdr:the banding et imen hfp ni n,old within oto year of 103 - UFER ., -"'
Im,p...c an,the uwnervhuilder will have the WNcn of proving that he did nm build or
prove for nurpaae or xalel. 104 — REBAR
_..- — —.. - — 105- = ANCHOR"BOLTS- —
m swar nl the property.am caclusively contracting with licensed uncommon to
t me project(Sec.7194.Business and Professions Circe:)The Contractor 106 - SEWER & WATER
Limn Law does no,apply ra an owner of pmpcny who Wilds or improves thereon.
.,and who.contricts for such projects whh.a contmetons)licensed paanant.m.ths, _ _. ._ -.20-2- - UNDERFLOOR PLUMBING
Contractor%License Law.
❑I am ext,cv's mul See. ' .a&PCfor this reaan 203 - UNDERFLOOR• MECHANI CAL
Uwncr
' Date 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby affirm ande,Penahy of Perjury otic of me following declaration,; 301 - ROUGH PLUMBING
.:• C 1 have and will maintain a Certificate of consent to sel6inwm for Workers 302 - TUB & OR SHOWER
Compensation, a, provided for by Section 3101 of the Libor Cade, for the
performance 0r me work for which chic permit i,i,cued. 303 - ROUGH MECHANICAL
ai
❑1 have and will manhunt Worker's Compensation Insurance,as required by Seciion 304 - ROUGH ELECTRICAL -
'37m of the Labor Cali,far the performance of tM work for which this Pe.,it is 305 — FRAME
isit d.My Worker Co npc rem on In.umnce Carrier and Policy nobel am; •u,,, - ,-,_.,,,-�•`
306
SrarEIFIANa, • Policy EMPTII : $OM WORK RS' "
;.n CERTIFICATION OF EXEMPTION FROM WORKERS' 307 - - INSULATION
. _ COMPENSATION INSURANCE .'." `.....-... .:.,_,--SHEETROCK ' -......
"'1Tlo,actin need not he completed it the Permit is for one hundred dollars 309' - SXTERI OR LATH •.1 t..
151001 or lcss.l
- _ .. ' _ 3-10 - INTERIOR LATH
s1 eerhly tont In the .in anance.h the wink for which this permit a Worker I
hall`oto employ any person in any ate w aCm become wbjec�to Me workers' 311 - SCRATCH "COAT
compeasanon Law.nrenlanmia.Date Applicant ..3.13 _- _ROOF. NAIL
t NOTICE TO APPLICMT.ILafternukingthiaCmifinuofEscmption.youshuulJ 501 - FINAL ELECTRICAL ENERGY
become suhjcm y the Workers Compensation prnvi,i shaof the lamer revok you must
O � fonhwnhrnnrpiywitnwvnprovninxntm,pennh.,nannedeamedrowrkae, 502_ - ..FINAL PLUMBING-..
ENERGY
`•-CONSTRUCTION LENDING AGENCY, 503 FINAL MECHANICAL ENERGY' `
'1 hereby ilRnn that there is a cansnoction lending agency for the perfimmanc<
x ► of the work for which chnPermnlai,wed(See30Y].Civ.C.) 504 - FINAL BUILDING ENERGY
p -Lender's NameELECTRICAL .. ... .._ . . . . .
cr . ` '- ' '", a. - - 505 - FINAL
.' z Lender's Address.. - ,
V'C 1 weeny char 1 have read ock ap,1i,mion and state mm the above information i, 506 - GAS TEST
Fcarted 1 agreet comply with B t d county ordinances and state laws relating 507 - FINAL PLUMBING
O V mbuilding consmozion,andhereby N nzerepresentatives
ur tin a of this city to t neon 508 - FINAL MECHANICAL
'ys 0. the b mentioned o IK rye pea P tp
La (we) g t indemnify ak pct )roan th� sea amPnn st.a,t 509 - FINAL GRADE
(O lion Ili<s judgments. t ed pcnses which mai any ay amine vgaigt said
V Z city n enwsmrn.eal the
grand,nf,h,perm t. 510 - NA ING
.AP ANT UNDERSTANDS AND W'ILLCOMPLY H'ITH ALL NON-POINT Issued Date
SO RrER; IONS. B-QI-.ZODI ��
Signature of A,plic.rVCtinmmh,r Date , ' Re-roof§0 - ROOF PLYWOOD NAIL
- nip Where hoicho,tivc a m tom Or handle ec Rolf- ROOF BATTENS
HAZARDOUS MATERIALS D
Wall the µiPlic t t h Iidiny pa t a nr b II h zallous matcnnl Type o§ - - "-' '- •" -
asdeft ed by the 912.and he Health and safety . 604 ROOF IN-PROGRESS t • n'
C&Ic.
EI 25532(h),t Nn i - 1
• l� All roofs shall.be inspected prior_[o,any roofing material being installed _.. _
W B,n pP1ic nt rtm rebuilding p t seeq p t d swhich If a roof is installed without first obtaining an inspection, I'agree to remove
en'Ih xaid
usr"Ohm"
t actin Iby the Ray Arco Air Q 1'q Management
Di, c all new materials for inspection. Applicant understands and will comply with
❑Yesy rFKNo all non-point source regulations. . _
' I 1 ha'vc read the ItumNoui materials requirements under Chapter 6.95 or the
California Health&Safety Code.Sections 25585,25533 and 25534.1 understand that -
"if the Wading does not currently have a rano,that it is my responsibility fa notify the
pant of the requi
rements which must be sect prior to issuance of a Certificate of
Signature of ApplicantDate
All
Owner or mu o'i"d figagent' - Date All roof coverings to be Class"B"or better
{'. - . . - .. �... . - .
' .... .. � .. ... OFFICE