01060020 CITYILDING DMSSIiouNOPERMIT CONTRACTOR INFORMATION:
BMDING ADDRESS: PERMIT NO,
OWNER'S NAME: APPLICATION SUB DATE '
WAR h' CONTROL NO.
a O ZO ARC HITECUENGINEER: BUILDING PERMIT INFO
m❑ - BLDG ELECT PLUMB MECH
G« r'-I f---I r I L_1
Z oNi' 1 hereby oBL1ICENSEDm ONTRACfOR'S DECLARATION r 9(commencing Job Description
O N-0 provisions a p e
F_Fw with Section 7000)of Division 3 of the Business and professions Code,sand my license :
m f is in PoII fo¢c and o Ha y r ` Lim.N b 0 )
U,
rc a License CI -% -61
M r� L��-'
xoau Data canuaemr RPELACE OLD A/C UNIT WITH
.3:tli Axe CT'SDECLARATION NEW CARRIER 5 TON AIR CONDITIONER.
rz
g 4u2 ala .�II be used a�p2m recrnds r
ea
do
L¢ensedPrf final y� F'INALED
n.K o OWNER-BUILDER DECLARATION
w-� 1 hereby affirm that I am exempt from the Contractor's License Law for the
I_ZQfollowingrcmon.(Section70JI5,BusincssandProfessionsCadc:Anycityorcounty
F JUL 0 _2.001 _
ts❑- whish requims a permit to constrict.al¢c impro e,demolish,or repair any swnurc
n 3z •.poo da,its issuance,also nal the ppl' tf -such permit m file asigned statement.
shat he is licensed parmuract to dre-jararrisions of the Contractors License Lam(Chapter 9
Sq. Ft Floor Area", t , , r Valuation
Ito nc ngwth Se rm,7 Q0)of Divi. J fthe Busness and Professmns Cod) ;'„� .B
o that he is exempt therefrom and the hands for the man
alleged emanation.Any violation
obILDA
f Section 7031.5 by any applicant for a Femdt subjects the applicant to a civil penalty
'.four mammon rnewmlreddulmrsa5W). APN Number �'-. . , ccupancyType
C 1,as owner of the property,or my employees with wages as Meir said compensation,
will do the work,and the swcture is not inradcd'or IT..d for sale(Sec,7044:'
Business and Professions Core:The Contractor's License law does not apply to an Required Inspections"t'.S:5 L
owner of pamperry Who builds or improves thereon.and who does such work himself 1 ,
orthrough his awn employees,.provided that such improvements art not intended or `
.oRedJ for sale.IG howthe e building or improvement u sold within one year of "' - '3'0 5 - FRAME'------- ---------''- ----- '- -”- ' --- - -- ----
iompletion,the ownenbuilder will have the burden of proving that he did not build or
mprove fm WyUn razle.). .307 - INSULATION t
__ _..-- --._ . ._._... ._ .._ ..-_ 601 -- 'ROOF -TEAR-OFF -" - - - - -- - ----
O L as owner of the proprnY,um exclusively contrveting wire licenses contractors m -._.._ 1 . ....... .. ..-_-
0
License thdreasOject ser.
appl7oaanBusmeoaand ertywhobaewer)]linCodiumeanuo,� 602 - ROOF PLYWOOD NAIL": •-";` . '
c License Law does rest apply to r o owner of a sonar who builds m improvrz thtiron; ...
_ . ane.whors Lvaau rLaw. projetts.withacomracmr(sl.hceasm parsuant mtM. .,.,_.. .....603 -'"ROOF-BATTENS----'.1- �
commmars License Law.
❑Iamcxamptn_nderS�." ",`ea,rcrmmar� on 604 - ROOF IN-PROGRESS"'" 1
odhe, Date - - -
WORKER'S COMPENSATION DECLARATION
II I hereby aRrm under penalty of perjury one of the following d tamtions.
C I have`and will maintain a Comficile'of Conscin m self-num for Worker's
Competwtion, as provided for by Section 3700 of do labor Code, for the
_ performium of the work fm which this permit is issues.
Gat have and will nixinvin Woikrr's Cour,rirtion Insurani¢,at required by Seciod
3740 of the Iabor'Code,for the performancs,of me work for which Itis permit is
!saurd.My Wor ea C mpelnIs�.to Insurance carrier and Pot dy bar T _
Carl rn.{jm7yTJ•mq.'Policy No, Y] S
t ERTIFICATTION OF EXEMPTION MOM WORKERS s' - s:•'
.. COMPENSATIONJNSURANCE _ -....._. .... ._-._. ._........_.._._.-._.,.._.._ ..._..__.__....__-..._...-.._._..._a_.._�___..-._- __ _-...__- _ ._-.__.___..._..-
fru"senionmNnot becomPlefed if the permit is fm one hundred dollars,
-'I i i":DI"' i.':'CP;`,•J::'. l' ;'
(11001 ar lass.'
Y Pt n any m . .... .. ............ ..... ... ....._. ...
I certify m the pert rnt a of the work fbe wh<h'th s permit a issued,l
shall eemployon taon r as m become sub'ct to the Workers
an
Compensation Laws of California.Ddtc 1
APPIm .. .. ._. . . _. .. .,.. .. .. .. _ _.._ .. .... -_...... ... _ _ .... ..
.NOTICETO APPLICANT It,after making this Certificate ofEemption,you should ! �• • .
become subject to the WOUlm S Comp rinomn pro z ons of the Inbar CO&.you Usual
O forthwith comply with such provisions or this permit shall he deemed revoked.
aZi••i . . .. _.. ...-._ .. .. _ .... ... .. ... .. ....... _... ... - . .. _r .... - - _ ... ._ .
CONSTRUCTION LENDING AGENCY
F' 1 hembY affirm that there is a comtracnon lending agency for the performance
�.a 1197.Civ.C.).,' _._ . ... .._. __...............
-._.. _-....._ ,.._..._._ ...-. ._.... - .. _- .__
rs issued(Sec.J
Lender's Name'-bleb this t _......,1. -.. ..... __'...-�_.. ,. ..
of the work for w pi
Z• Lenders Address" - - 7-t
'
C.3 0I cenity[hat 1 have lead this application and.tore that the above infamiaion is
k• [�
C) correct.I agree to comph, II city and county nt non d oate lint re
to building contraction,and hereby nt livof h 'tet et upon O
It above-mentioned the pP pent far inspectionpurposes, ... � '
E„t I•y (W) g 'm de f nd keepharmless the Cty'of Cu,ennoagamt d
71 liabilities.jdg ens.costs and a ,raze. which may-in any way decrum againot said �J
Q Z City in consequence of the granting of this permit. ''-�
'-' APPLICAN UNM STATSOUR SANDW'IL h1PLY WITH ALLNON-POLYt ISSLLed by�`J CCC. L Date 111) V�
sg LAn�"cantmcmr 6 sole Re-roofs
HAZARDOUS MATERIALS DISCLOSURE '
Will the applict fi buildig -pair vweo bawl hnaardous niavn'al .:.Type of Roof - - •-. .. -. _ .. .... -,.. .._-
as d r d by the Cuperi M m Pal CodCh pt 9 12 rid Ili Heads and Safety `�
Cw CYez SSP(al Nn'
... - '� -_ .... All roofs shall.be.inspected.prior.to any-roof3ng.materia]being installed.
Will he apple t or f m building Occupant use equipment oa ices which If a roof is insialled'without first obtaining an inspection, Paoree' to remove
too.
hazardous air t t I. y
dented by the B 'AA Q fgem
Quality'Man
o t t re all new materials for inspection.. Applicant understands and will.comply,}vith
too ❑Y o -`�I •-all non-point source regulations:.-
,,•, `I,, . .
I hare.rcw the hamNuue m:ncrials in under Chapter 6.95 of the
California Health S Safety Code.Sections 25505:'_5533 and 25534.1 understand Nat _
if the builtling dos not cuircntly haveamnamahm
I,,,my rezponsibiliry to notify the
occu70.
�a rf the Tretorn which must me poor m izsuanae of a CeniFcam of
ata aw .- Signature of Applicant ... --._ . _.. _. ... Date
- -
' Date. All roof coverings to be Class "B" or better t
1.
Owner o agent _ -
OFFICE . .- ---- '--