01080132�i
CITY OF SIIONNOPERMIT
CONTRACTOR INFORMATION:
DIVIS
BUILDING ADDRESS:
PERMIT NO,
21558 ROSARIO AV
WATER HEATERS ONLY
01080132
OWNER'S NAME:
APPLICATION SUB DATE
HOBDY WILLIAM B AND CAROL A
970 E. MAIN ST, SUITE 20)08/28/2001
PHONE:
(415)566-2209
SANITARY NO. CONTROL NO.
Z ARCHITECgIENGINEER:
BULLRING PERMIT INFO
BLDG ELECT PLUMB MECH
IJ L'J I_J I—I
d
Z L,IhotIDCONTRACTOR'S DECLARATION
Job Description
1 umnIncuch,not affirm thus 1 an limned under, Prorisirns n(Chapmr 9lmmmencing
to withSmion 700(1 of Divisirn3orthe Busine.tt end Profcssion>Codc. and mylittnse
REPLACE 40G GAS WATER HEATER
is in full force and effect.
SLicense Clues Lic. is
Dam Convector
v ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
y OWNER -BUILDER DECLARATION
1 hereby affirm chat I am exempt from the Contractor', License Low, for the
N following motion. (Section 7031.5. Business and Professions Cade: Any city memory
$700
Zwhich mouires a permit to compact. alter, improve, demolish, or repair any svucture
tts w -Prot s e. also9 N
es epplicanr farauchparmu t II bed v0ement.
- th the itl std Owitiamtothep ".-ons of Ne Convenors L' Law chaptcrY
Sect ](P(RfD'ision 3 Busmen dPmfessions Code)
Valuation
loom 5 with en opine
or that he ii exempt thin from and the basis for the alleged ekemrton. Any violation
I
-of Section 7031:5 by troy applicant fora permit subjects the applicant ma civil penalty"
arnar mare ndn five hundreddollars
502APN ''Ifo PLUMBIN
ENERGlOccupancy Type
❑ I, as owner of the progeny, or my employees with wages as their sole compensation,
-will"do'the-wark. vnd me Snuctur< Isnot intended or offered for sale (Sec. 70i+.''
Business and1Rofosiom Code: The Conimcior's License Law does not apply to an
507 - FINAL pI1KMft$I(9spection§-, �`
owns r of p ..pen, Who builds or improves thereon, and who draw such we& himself
or through h nix oxo employees. that such int arc not intended or,
t
_ __t'—n:' _ _ .
envois sol
W Wilding
,pHeice i,r Som. If. naevr. m� bolding a, iinPmnmmt is Sala within ono year or.
_ _ __ _
I
completion, the mer Wilder will have the burden f proving that he did not build or
-
-momm e for pinfoxeo! ).
(
_ _
'O l: o" nr rte pmp<ny - d.vNyc t (g with licensed convecrorsm
I ' .•
est r he Foulest, (Sec. 7044 B ncas and Pr f .. ns (Codc) The Conwcmr s
f
Lin Ia itnm apply'tar of p pony Ito build. p s the o
and h e rte t for. h p 1 n with o r t rt) licensed p am to the
Cut I ec La .
m
❑1 exemptundoes '.B&PCf @♦reason
�l'•i ,r. i..
"
Owner" ''" Date'
✓
" WORKER'S COMPENSATION DECLARATION
1 hereby train underipenaly of perjury one of me. following declarations:
p I have and will'maimain a Cenlficate of Consent to self-iawm for Wookeis
Compensation, as, provided for by Section 3700 -of the Labor Code, for the.
performance of the work to which this penNt is issued..
❑ I hove and will rtuinuin Wodei
Cfobrmmpmeii ofri
lin m requirelh]i
TW oPthc'Labor Coil, for rhe , betooork, zbPermit is
n
issued M' rium
t
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Cumy -.y 1 aR.r (1 :pultybit;
It
,.f t CERTIFlCATIONOF WORKERS,\"
-COMPENSATION
" ENETION INSURANCE
INSURANCE. 17t
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rn(Th fsed'n.11,neen. ben nPleied if the perm error one hundreddollars'
v.
PX,•i 1 n'•i 1'„q"..IIC\' I..j c'
IS100)err less.) s.cf •.•.. ,.
t
..' 1 cemf,that in the m c fin' rk! pc istimedI
y
:. �q' _t .,t 1;�, 1; .
in Ctor. ul
Com t PI Y w y pe(b troy niter so as 16 become ti)ect t th- Workers
•. ..
Compensation on Lows of Cabfumta DoreAffil'
NOTICE TO APPLICANT.If:after making this Certificate of Exemption, you Should
become subject to the Worker's Courripeavidooriposvishons of the Labor Code, you must
sh
fimhwitli nmiply with such provisionspermit shall or this perall be created revoked.
0 CONSTRUCTION LENDING'AGENCY
to ,�
lonhe perfoirnance
by almihm thcic is a coned. 1097.
-'• ' � r' `tl'. u
(Send
.film woo C,v: C IY
ofau. k'I men th les nil rued lS J1147'CIv.C)c,
-Lender Nm
Landers Addicns
• ,
ICemify rh r 1 have read hil applicationd state dvuhe above information, is
corittt I agreeto comply lh all city and county ordinances and state Irelating
inbuilding csonsomcflor, aitclh rchy authorize re6resimudiesafth. city to enter upon
L. the bo e e t dr.'se! nd f inspection purposes./
/�/ ♦ I� / ✓ix
�„
di Ory r against
L (We) gre ,,ser indemnify and keep hamay
of
open
s which may in any waycomeagates said
p costs and i
,UK
City i tin minors,
n,ofI
City in 2onsequdnei of tne'smming of thin Pcrmim' ' '
APPLICANT UNDERSTANDSAND WLL 12 COMPLY WITH ALL'NON-POINT
Issuedb Date
Y'
SOURCE REGULATIONS.. ,, ,','.
Signature, of APPIic t%, .t' .: Dae'.
Re -roofs
HAlARDOUS MATERIALS DISCLOSURE,
. w n m' Ppuea t rid Wildingoccupant tore err n dl e n int s material,
Type of Roof.
as der d by d C pentno Municipal Coda Chapt 912. and for, Health rand Safety.
rr ' •al ,- :•I ,
{ i
Ciid 5 to 255321v) rs .tltf r R
oY< ❑n (I," i 1` i;.,
s 1'. • • 3
Al] roofs shall be inspected pnor.to any.roofmg.materia] being installed..
' .Willthcapt rp'ca f mboldingoccupxmuseequp to,datwinch
If a roof is installed 'without first obtaining an ingpection,;Itag'reelto'remove
emit h d oro t d r cd by the B) A A Qu 1 ty Mawgeme t
Rini t
all new materials for inspection. Applicant understands and will comply with
• or oN"-all
non -point source regulations.
1 brve'read the hazardous rnutcrials rcgmrnnems under Chap¢e 695'of the,.
d Health &Safety CddKSenions 25505.25537 and 25574. bundmtvnd thvt
' --
"doe1-h
i(tfie bvil not currently haves t<nam.thm it is my responsibility to notify the
-
offie"s
niuiant M,rbc,icquiremenii which moot be rne� prior m ,nuance of a Cenifce¢ or
O"ciip "`Y � t ` `. " .. ' ..,
Signature of Applicant Date
_ .
All roof coverings to be Class "B" or better :
Owner orvmhorittJagcntj ! Date
..-_ .. - OFFICE