00080156�k nut DING DIVISION' PERMIT I CONTRACTOR INFORMATION:
BUILDING ADDRESS:
OWNER'S
CO'LC ARCIIITECI'/C GINEER'.
,uu
S?Z' LICENSED CONTRACTOR'S Df;CLARATION
hereby aAirm drat I sen licensed undo, prow..tuna of Chapinr 9(commencing
C w
,,It ScOimr 7111X0al 1) u 31Ilse lin ...le"and Po'ba"inn. Cndc. and Inr liecnso
at L linea In ILII and the, � �% q 3 ?
at ¢ License Class Lir.M
c. Date L Conrra
¢S 3 G `� AHCHI"fECT'S DECL\RAfION
1 understand my plans shall be tired a, pu he record,
on
ce m o 'per Le,owd ['oil ... innd '
OWNER -BUILDER IIECI,ARAGON
ea
1 hembv whim that I um exanpr from the Couraaor'. License Law fav the
fallowing reason. (Section 7031.5. Business and l'tnfessions Crile: Any city nrcnumy
�X ❑ which requires a permit to conanrm, altar, improve, )modish, or repair any structure
1Z. p.lo.er lis ixaruncc. ul... rnryire, naupple: ito, such pe nn it file u,igncd"amount
a 3 — mat he I% licensed par. am to me pro of me Cunlractins Uaea,e Low tcnapler9
(c nninancing with Section 700(h or Div Flan 3 of the Businssv and Profen ion. Code)
or that he is eweept therefrom and the bases for the alleged aenrption. Any violation
of Semon 7031.5 by any apPlicam for a permit subject, the applicant to a civil penalty
01not more man live hundred dollars ($51X).
01, un none of tiro pmryry, or tar cniplo eo, wuh wage, a, theirs nl,corupcnvtmm,.
will do the turd., and the swcam is nut intended nr offered lir, sale (Sec. 7144.
Business and Profession, Code: The Coleco,', Limew Law does not apply to an
r of purpeny Who nand. o, Inrpowvn thereon, and who does sttoh work himself
or drought his own employee.provided that such impmvemems are not intended tit
Cffecd tar ,ale. II; howewc,, the houlding a, itnpoovcment is sold wllhin tete year A
,tudet the mmnerbu ldor will have the burden al pawing nett Ire did sen hold nr
hnprnwe for puryow of dcc).
01, a, owner of the property. an, e,clnavey contracting with licensed contractor, nr
1! vvt S,,.nucl me pot ,,. ]414. Ilnxincu, and i'mtirowiun, Gale:) The Cm lr,vau's iccnvc haw doe, not appy m an nwncr of ,,, Ily woo fault, set hupnrvcs meteor.
and who ucrrav s or such prjeco with a con(rwclud,) licensed pursuant to the
Conlracoo, License Law.
01 .,it e,nnpt under Sec. . B R P C for this reason
Own, Date
WOIZK17R'S COMPENSATION D1iCLARA'GON
1 hereby affirm under Irefully or perjury one of the following declarations:
❑ 1 have and will tnairnain a Certificate of Conant to self -insure for Worker's
Cntnpcnxtnion, a, provided lin by Section 371000 of the Lubar Code, for the
pe Intnl:uaC of lltn wnrk Ill this permit Ins issaerl.
have and will minium Worker's Co mpseseion Insurance, as required by lection
r,]t of the lava Calc, for he performance of the. nark for which this permit is
rd
tu. My \moor', ConlWav,atien Insurance carrier and Policy rounder am:
COMPENSATION INSURANCE
Orris mlion need no, he .... onem l if the panni, is for ane hundred dollars
I$ lot)) or less )
I verify the, in the Perlin:mace of the work fur which :his permit i, ivncd.
shall not employ any persan in any insurer va us In become object h, lire Wade".
core'dsaion Law, of Califemia. Due
Applicant
NDGCh TD APPLICANT: I1: after making this Corircate of E,crudion, on xnedd
Z nano: eatbject wore Werk,m, C'utnp.nwtion pw eh rat,of:n, l.uhnr Code. yort nna
O O forthwithaan,plr wim.aan pmwialmr, or thin front,shoo be deatnm rewnkad. t
z ,
(✓ ^ CONSem is a ION LENDING AGENCY
ai 1 Hereby which the, there i, a construction(,.lending agency for the peefnrrvnec
uta of the work lin which Ilii, permit is uuueJ l5eu. fl)K)]. Civ. C.)
S Q Emile', Name
LsnJer'a Address
U O 1 ccrify that 1 have read this application ..it arum that the aKim interaction i,
,neat. I agree ser comply with all city and county ordinances and slate law%echting
O U rebuilding construction, and hereby uulhorim opowntaives of this city to canal upon
rN] ora annve.mentirnnd Pmpory by nspactina pnrnnwa,
IWc7 agree... me, indennril'y and keep harnil... the City of Cnponino nguins
iA liabilities. judgments, coats and crlrenaes which may in any way accrue against said
U Z City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITM ALL NON -POINT
SOURCE. REGULATIONS.
Signora of APPlic.uYConneetnr Uam
IIAiARDOUS MATERIALS DISCLOSURE
Will he applicant or future building recuphat .sec or handle harnrdou, rnamtial
sea defined by the Cupedine Municipal Crile, Chapter 9.12. and the IlcWth and Safety
Code, Station 25572(107
❑Yes E3No
Will the applicant or future holding Bacup all use equipment or Jcvices which
mit hazardous air cnarni ams as Jelined by the Bay Area Air Quality lstam
nugeent
m
inriao
Bye, 0 N
I have read the hazardous nmmrials monimnamt, under Chapter 6,95 in the
California Ifealth h Safety Cordo, Sooners 25505, 25533 and 235:4. 1 undersand (hat
if rhe building Mos net curmndy have a mount. than it is my respail ibiliy to county the
occupant of the requirement, which must be met prim to issuance of a Certificate of
Issued by:
Re -roofs
Type of Roof
I'i?ItAIII ' NO.
r NAT
Lp l\P ,.KATION$ It ATGTVL 1
'e '4n' ,,-""Y1 ' SANITARY NO` 8,'2^L"OCTRU
D)293 -550t BUILDING PERMIT
A ADO, 9111C'I' 1,01,111
1 L 1 L1
Job Description
REPLACE 40 GAL. WATERHEATER
9 Det—'-W4�`i.rired Inspections
1.06 —
SEWER & WATER
202 —
UNDERFLOOR PLUMBING
301
— ROUGH PLUMBING
302 —
TUB & OR SHOWER
502
— FINAL PLUMBING ENERGY
506 —
GAS TEST
507
— FINAL PLUMBING
all �Z7
/Q
O
Date
All roofs shall be inspected prior to any rooting material being installed.
If a roof is installed without first obtaining an inspection, 1 agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
f
Signature of Applicant Date
All roof coverings to be Class `rB" or better