02010134 OF
ct BUILD NG DIIVISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20791 SCOFIELD DR TEMBROCK JOSEPH R AND JU ITH A 02010134
OWNER'S NAME: APPLIC9TION SP DATE
TEMBROCK JOSEPH R AND JUDITH 01/ 31/2002
PHONE: SANITARY NO. CONTROL NO.
q Q ZO ARCHI ffiNGINEER: BUILDING PERMIT INFO
kC,R- BLDG ELECT PLUMB MECH
a Z W fJ CI 1—J L=J
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LICENSED CONTRACTOR'S DECLARATION Job Description
OZ'sG IherebyaFrmthaslamlicensedmalarprovisionsofCM1ap,er9(emarmncing REPLACE SHOWER
rr:�u witM1 Section 7lg)B)of Division 3ofthc Business and Professions COJe,and mylkense
�mg� is I. affect. FINALE®
z 6 a Liana Clasa Li<.a V
O U Dae Contractor
w ARCHITECT'S DECLARATION
g 1 understand my plan,mall he lad as public records FEB 19 200
E:p o Licensee P-fessi.nal
ouOWNER-BUILDER DECLARATION
I hereby offirm that 1 am exempt from the Cont-aor'a License Law for the
z a outlawing reason.(section 7031.5.Business and Pnfica, in Cuda Any city a r onry BUILDING 3 5 0 0
pp O which e,aincs is permit to construct.itiort,improve.demolish. p y structure
6 er
mprior tots issuance.fibut,inquireasNe applicant fsuch permit to file a dint statement -- -
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thatbe islicensed part to the provision;oftleContractors Lc La (Chapter9 ,was �<,�y,�r.s a•: Valuation
(c m r< th Srcu 70(10 f D sr 3 r,n B ,roe, and oessmns code) 'k
onhabe desempt,herefrmn'und he basis for he alleged ekimptwe.any violannn •_U. 11',... / .,,y.,�
of nottmadendar vany undre icamrs(SS for a Permit subjects she opplicmuoecivil penalty 106AP-NNEWER & WATER "ITT>,., Occupancy Type
1 o not more than five hundred collars(SSW).
°1.as owner of the property,or my employers with wages as their sole compensation. 202 UNDERFLOOR
.__ _ .-. ___ _- .. .__._
"'w II r the'work:and tM1m adore tin tr nor i Lice se Law doe sale(Sec. -' --- -' '_-"- "
town r-a pand sFaiiny W ons Code.The Contractor s thereon,a d w Low acts not apply m on 3 O 1 - ROUGH PlEiltJ§ �tWl$spec[ions `•d''
owner 302 - TUB & OR SHOWER
or through his own employees.s. build-that such impmvemems art not intended or
nrtereaTdr alae:Ir.n.wever;the building -m..v<mem issold or -` ----'- - '-----'--
geor b p r 502'--'FINAL�PLUMBING-ENERGY -----%,'�:_
Iimprovtion,the onse.fbuilder will have the burden ur thin he did not build or
improve for puryose of sale.), p.rang 506 - GAS TEST e
of the property am ex<IusivdYcomrxting with commcmrs to 507
rst-eethe`project(Sec.904,1,Business and Professions CWelicensed:)The Contractor v 512 - FINAL HANDI-CAPI a'-I1. E1- ,'t., ' %fi
License Law dues not apply to an owner of property who builds or improves thereon,
=' - ._apd.who contmers.for such projects withocontractors)licemed.pursuamlo.the. ..___._ ._...._.._.____._ ._-_.-__. . .__..__...._.._._.L_.._.___.._
Comracwre p m`c Sec
s, ;" •.
❑lam rapt undrr Sec. ".B'A,P C for thisrc
71 1w
WORKER'S COMPENS'A'P1ON ECLARATION
! u I hereby affirm under penalty of perjury one of the following declarations:. .
° I navy and will maintain a'Certificate of Contin,teself-insure far Worker's
Compensation, as provided for n
by-Section 37W of the Labor Coca. for
_ - 'performance of the work for which this permit is issued...
°I havesn t will mainmin Worker's Compensoimi lnmu-rice,as required by Section
37W of the Labor Cash. ne,for the Performance of the work for which this permit is
isiued.My Worker's Compensation Insurance comer and Policy'momber air. ' _
Cartier:`t: :. C: lid#rt i tnapiPolicy lvu: s to L. •., (.l -.a(.Gdi''..a. r- Yit'Ciiafil: ,..._. -.- .
;s'',CERTIFICATIONOFE%EMPTION FROM WORKERS'k^ 't..f�:1•j >,�.,{,�"'f i)"i. �,9u 1.�.i•.:�yl.�I?Af.l�4�.
' - COMPENSATION INSURANCE
(Tho as on need not be compined,f the-emits for one hundred dollars
IS i W)or Is,'.),
`r' Icetr lha''in thfortn'nc fth - ..klthis
y pe home,k bpe t . rcor e l .... - t L:::
h miter eman Laws of
son p any moon to become A) ,too the Workers'
Compensation Lows of Califossiia,pate'
Appl cam
bQcmac TOAVo the War If ft kingth' o si Tela,titE pi you should
st -
Z bccomv. comply it suchpsC iwas or thin pm nk of theLana Coda you est
z O fonhwilh comply with such--visions or this permit shall br deemed revoked.
r.p2 "'+'CONSTRUCTION LENDING AGENCY
1 h by 'ffrm d t tb' const ti lending agency f to µlvarmance
of,,a
work for whichim,pem,it is isued(Sec.3097,Civ.Q)
LanderNo.
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td
..O Lcnacr's Address,
I ready that 1 have read this application and state that tire doasi,information is
ka•:[ti 'cone, 1 agrc<to n,tnply.with all city and county ordinances nd.t laws relating
to Wilding conxwnion.and hereby omhonu rtprtanmtiva of this city menter upon
the abnvementioned property for inspection purpoxs._ _ __ •-.
p..G '(We)dgrte ioalae.indemmfy and We,ha.nlrss the Cityof CuWidgna against
-N
limilaies,judignams.costs and capeties vshiah may t any way cccame ispsio,l said
C,7 z City in coracquenceof the giantingi ofthl formut.'
APP c�0U1DERTANDSAND WILLCOMPLY WTPHALL NOSPOINT Is$Ued by: Date
ng s}�T �p^�l♦ / 7
Stg s l Appl'�.m/Com t' "' - iia,
I' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE l'�;
Will the ppl atorfmte buld-gacpant.mrtorhandlehaiadou mat I Type of Roof
def ed by th C pen hfun ipal Coe CR pt 9 12,land th He its J S f tY l I, t
Code:Set 2551 (aI s .-, r: t*. slis ' L
.en
°Y
All eroofs,shall be,mspected.pnor.to1any iooffng material being Installed.
• i u III pplc 't. futureW m-goccupant- rgavmenr.rae a,wnrn If a roof Is installed'without first obtaining an inspection 1 agree to remove
nut h d-m,air rinuagnigarts as defined by the Bay Area A by hl Qualnage t
Dist 1 ..
all new materials for inspection ,Applicant understands and will comply with-
°Y' "" all non-point source regulations
.'I have read the hoaardcon,materials requirement,mode,chapter 11.95 of the '
,Califoiria Health&Safety Code.Sections 25505.25533 and 25534.1 understand that _ _ __ _ _
'If the building ares not currently have a tenant,that it is my nesponsihiloy m salify the ""' - --
_ `occupant of the requirements which must be met prior to issuance of a Cenifmae of
°" "`Y' Signature of Applicant_ Date_ _
- /- _ . _ _
Ow r antnmuecipgert J.. ars. All roof coverings to be Class "B"or better .,
:.: ::1 .,_..- �.,..r. .. ._. ... . .OFFICE-'-