00080145BUILDING DIVISION PERMIT
BUILDING ADDRESS: _O _ A n
OWNER'S
PHONE
CONTRACTOR INFORMATION:
cls
CONI "Rol, NO.
M p ARCHITEC'rIENGINFER: ...............
..............is..........
. BLDG ELECT PLUMB MUCH
2 u I -j L=1 I-1 L_I I _1
a
S v Z
LICENSED o C(IN'TRACfOR'S UKLARA'nUN Job Description
0Z=G thereby VI'l )I..Ium'or in,Bunder provisionsof Ch Colo. audit,
ncroe
-yy.re with Seedinn 7011fp of itis' nn7nf the llunlnc6s and Pmkssioolv Colo. and my limnw
Yf is in full force and cffecl, i,i
z5< License Clax. Liv.M
a y '
RECONNECT POWER LINEa U Dau IARC] 111IiLT'S DFC.AI11I'ION
5 g 4 1 moderated my plans shall be used as public records
51
u z O Lianmd Podeaaonal
i d o re OWNER. [I UILDER DECLARATION
"m I hereby u(fmI that 1 am exempt fmm the Contracu,r's Limns, Low broke
C ] lollowin.....ot. (Seel 7011 S, Busins,s and Pnde.aion. Cade Any city or county ,
O which requires a permit nt comtmct, o cc improve, demolish or repair any structure
c, prior to its issuance. also tegolres the applicant for such Femur to file a signed statement
that he ie licensed purauao.tothe p.,,I..onsuf the Coneroun, License law(Chapter 9 Sq, Ft, Floor Area Valuation
(,( nueaing will Seatlnm 70hdof Divlsin 130 the Business and Pnffes,ion, Coolfo
or that he is i sempt IhemBom and the h:Isis for the alleged exemption. Any viall
of Section 7011.5 by any applicant for a Permit subjects the applicant 10 4 Civil penalty
of more her live hltmlrcd dollars ($5011t � APN Number Occupancy e
todds, progeny, or rip ' employees with rages as their sole compensation.
i , i owner
Lit, work, and (lie structure is not intended or ofered ha sale (See. 70W.'1
Business and Profir"luns Cn Ic rhe Contractor's License Lnw docs non apply In nn `s r' I C hired Inspections
r of m),by Who builds to imp ,ovIn, thereon, and who do., suchwork, himself
or through his own employees. provided that such improvements ore not intended or
Aficled rte sell l L tin r. It, huildh:gat int at is wdd w'uhin^eyes of 304 — ROUGH ELECTRICAL
em
aprove`or purose)I sale.), 501
have lite n�rden nr proving tlnld he did lt�n nail,ar 501 — FINAL ELECTRICV_ ENERGY
imvm,e nat(aaen
❑ 1. as uwrn, of the pm,ori, am exeh"Isely cmtbaning wilt liccn,cd eonioelmx m 505 — FINAL ELECT R L
onutmet the pmjeel ISec. 76 , Politics, and Pn:fessiol., Calla The Contractor"
License Law docs not apply In an owner of property who builds nr improves Cher om. /
mrd who 'ntact, for wen p,ojrcds will, n camio,rnw licuna•J p..trout, to dw
Conuano s I use Law
.
❑lames B&I'Cfor this reason
O cr _ W'ON :ER'SCOMP IECLARA'fION - O
I hereby ullinn Inter pcnupy of pajnry Inc of the following Jcclumdinnn:
V
❑ I have and will maintain a Certificate of Current to self -insure file Worker"'
Copula, va(unh as provided lar by Sermon 3700 of the I,ohnr Odf,. fur the
performance od the work for which this permit is Issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37W of the Labor Cede, kn the perturniance ill'lite work for which this permit is _
issued. My Worker', Competition Insurance carrier sold Policy number Ire:
Carrier: Policy No.:
CERT IIICAl ION OF EXIIMFI'ION FROM WORKERS
COMPF.NSATiON INSURANCE
(",bis wain. need no, be completed d Ihu Pondrit is Ind one hmtdrcd dollar t
61U11 oe less.I
I eernly Ihat it the p,it unnan.. ill' Ihu work tar which Ili, cmad Is issued, 1
shall not employ any permn in any manner sol as to become -i Io doe Woekes.
Cnmpclrminn laws of Califomire Data
Applicant
NO[ CETOAPPLICAN-1: IL odic, making this Ccmidilam of Exanpnion, you should
necnnte subjsauo the W'orkeJn Compensation pntvisions of the Lrbr Gde. you must
Q O fnnhwithroatply wllit such prnvisimtx or this permit shill he demned revoked.
FCONST RUCTION LENDING AGENCY
1 hereby affient that them is a construction lending agency for the porfor arom
it'the work bur whleh Ibis penult s issued (Sec. 3007, Civ. C.)
Q Lender's Name
:'7 7 Lender', Address
U Q 1 ccnify that l have read this applicminn and sate that the above inhmnaton is .
crurml. I .,me to c1 ply wins all city and roomy ordinances and sate laws Mining
Q U to building cunstrection, and hereby amhorim representatives ofthis city oil enter upon
the ah-e-mcmioned papery rte mspeuion purposes.
(WO agree to once, indemnify and keep harmless the City ill Cupeninu against
rA liabilities. judgments, casts and expenses which may in any way acme against said
U u CIIy in consequence of the granting of this perntid.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT Issued by: Dale
SOURCE REGULATIONS.
Slgmutnm of A,dFv II/Contractor Dam Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding occupant start or handle hmardoo, mamdd Type of Roof
to dcfmal by the Cuperdnu Municipal Code, Chap¢, 9.12, and the Ileallh and Safety
Code. onon 25532Ia)4
OYes 0 N
All roofs shall be inspected prior to any roofing material being installed.
Will lbcapph"nonI,,Inlembodkin neetile Imltnea,I....n...in"evmeswlu'll If It roof is installed without first obtaining an inspection, I agree to remove
emit haralde is air conlammmils as defined by the Buy Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
DYcs ClNo all non -point source regulations.
I have read the h .... do , materials nod immems under Chapter 6,95 of the
Culii'ornia Health dr Safety Cud, Sections, 255115. 25517 and 25534. 1 understand Thal
flue haldin, does Qp end adv u sen:vu, thw id is lnY rvnponsihllidy la nobly the
love of 4em no, w h I,.,( be, Intel f nor to issuance of a Catifivem of
CociMacy e Signature of Applicant- Date
awne Imhotiaedagcut Date All roof coverings to be Class "B" or better