02040036I
CITYOF
BUILDI G DIVISION
PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
22461 ST ANDREWS AV
WATER HEATERS ONLY
02040036
OWNER'S NAME:
APPLICATION SUB DATE
WANG LING -RU C AND ALEXANDER
C 970 E. MAIN ST, SUITE 20)04/08/2002
'PHONE:
SANITARY NO. CONTROL NO.
(415)566-2209
ARCHITECTA NGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I C_1 C.'_J I I
p,ta Itc. cnRtl undcRr
Job Description
I hnebyaffinLICENSED
Prov onaAofcit r"ersmnmmeneing
with Section 7000) of Division 3 of the Business and Professions Code. and my license
REPLACE WATER HEATER.
is in fun rare and meet.
uanx Cla... Llc. g
(4 0 GALLON, GAS)
Date Contractor
ARCHITECT'S DECLARATION
I undersand my plans .shall he used as puhlic records
Licensed Professional
O\YNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Prefe,donn Cob: Any city or county
which requios a pemdt r: emraruct. aher, in,prave. dnnalish, o. repair any nmcmm
prior m its issuance, also requires the applicant tar such Perini( to file a signal statement
-
Sq. Ft FloorArear.•
Ar Area -.
auation
thathelslimns'edpuaulmtu(heprovi.ionsoftheCnmmcmrsLicenseLaw(Chaptar9
(commencing with Section i]11ao1 of Division 3 of the Business and Profevaions CWel
., �t.. C. is r•'. !
or that lie is exempt 0ciefmrn and the basis for the alleged exemption. Any violal)on
- -
-of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
ofnoe mann than rive hundred dallarn(SSW).
2 AA
A umber
.g 1.. Occupancy Type
❑ 1. as owner of the pmpeny, or my employees with wages as their sole compensation.
will do (Ito work, and the slrocmre is nor intended or'o Rened'r., sale (Sec. 7B ,
(Business and Pone,00ns CWe: The Convector's License Law dues nut apply to an
506 - GAS TE S'Fequired Inspections'%'
owner f property Who Milds or imposes (hereon, and who does such work himself
own o
.,in g(his own emever.t buildintoraucnimprgamen¢arehinmtengWor
'oRcad'fm lf. Howe (Heb Ian ( IJ tri' r
... 50 --- FINAL_. -PLUMBING ______. _ ..
..—._ _ __ __.._
.sale
completion. oomenbulderwll have the M1trden ofpmvng that he did not bild or
iampletonthe
mprove In, pmposc nr.vale.).
Ind, �s �wner ohne pope.. am iva)r ensN comrtnoa to
.! .. , . .., .
nsCostrumr's
Ina Professions code:) The
construct the project (sec. Burin d Professions
po! b, 1 f1
to a owner o improves (hexon,
License Law does not apply man owner nr pope. who builds
. .
seimprover
uch projens.wieh.a.conraceorts) licensed pursuane.m the.
and who conmense
__.__._._ __..___—__._.. ...____.....
_... __. __ _ . _.. ._. _._ ._. .... .____._. _ _.___.___._.. _...
Limns Ww:
Lai
01 ma
❑lemcncmpt order Scc.'
��yy B&i Cfor the mason
t(n�r �iamr,u.of
DpOn�1 .O..,AI1Rb.l
1.1iR .1 I IUL
`�,,t5
WORKER' CO ENSJRIOND CLARATI
�r
the following
' IherebYaRrmunderpc Y perjury ,. B ns:
BUILI,Yiru
O 1 have and will maintain'a Cenifcate'nf Concent in self -insure for Worker's
Compensation, as provided for by Section 37W of the Labor CWe, for the
Performance of the work for which this Permit is issued_
❑ 1 have and will maintain Wader's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of to work which (his permit is
p 0 A Y L�
LE
issued My Workers Conpcnsanon Insuranceand Policy be re:
�� � V /�
Cam 1. i,. 1 lv'POW la. ""
- -
.(- ". 3. /. .t' 1 T
( s, f.4. '1
'Z0OZ
CERTIFICATION OF EXEMPTION FROM.WORKERS I-
.' pprl
O
.... _.. _:.... __ COMPENSATION INSURANCE:.l_
_
r 1°' (Diii saciion need not t<cdmplacd if the permit is for one hundred dollars
i
L.
dflicm k'f when this pc ; t isorke I
.•:r' 1' ntfy than in the Iliin
•BUILDING .....,.... ....,..- ..:, ....
rL
m Iny manner sit as to become subJen m rhe Workers
Ccurnot employ any any
f C.Iin
Comicant maws of Califomil:Date' '
Applicant •. '- .•'.: - - _. ... r._
.. _ ...- .. _.._.. _.___. _.__.. — __ _ _ __._.
NOTICE TO APPLICANT. p C should
sof ofExemption.Laborde.
IL afterolpenn
•'
tion ixxoi st
became the Work Compenxnan pro sll the labor Code, you must
y
such pr
forthwith ciniiply wdM1 such provisions or this permit shall be seemed revoked.
conics y
..t. .-... ......
(Jy "'� CONSTRUCTION LENDING AGENCY � ' � ' �
"' ' '
' n Tor the perfaraance
r-which that (nem ti I conid (Sic. IWT ,
.t .
e w k farC C.)
ofthework for which this arms( is issued (Sec. 309]; Civ. C.) "
-Loader's Name,_ :. �.... _ .__..:...,,:, .. ...._...... _..._ ._ _.c.._.+s. _-.
_ _ -... . ____. _.
Lender's Address
, I nfym (Iha JM pplcm J to thnh W f tion is
oven 1 agree a complywith II city and county ordinances d e I relating
m.t
Wilding
Findherebyfor erli. p rives of Nt city to t upon
s
,he eM e t ed property fes n pc ria purposes
d r
(Nju li e( ate d keep h I ss th City fCupcmn
aid
peand
m,
fuses and engem, which may in any way deme against said
City c' - 4 c f theNgranting finis L a "'
City in consequence
APPLI ANT UNUER5TANDrS AND WILL COMPLY WITHIALL NONPOINT"
r'
01. REG AnnN µ' z
Issued b ' Date
Y•
A < n P t`'
Re -roofs
HAZARDOUS TERIALs DISCLOSURE tIINe
pCapecuhatr9 oc riddll an
7�,
���c
.._Type Of Roof -
Health Safety
y pcCh Pte 9 1 mJ the Health and Safetydh teC
YsR,t��
_ All roofs -shall be inspected pnor to any -roofing material being installed___ _
_ - _-,
Will the applicant future Wilding e P e use stir e devices which
If a roof is installed without firs[ obtaining an inspection, I agree to remove
emit ba ardor, air corm nares as defined by eche Bay Area Air Quality Managerncne
all new materials for inspection. Applicant
.._. , is f .PP understands and,will comply with.. _
gpe
all non -point source re ulations
Phase read che hanrd . materials r qu a Fax'mda Chapter 6.95 of to
IuMersoW the
Safety CWyhave ions8505at
Cmifdinilding
- _ -„
ifehe Wilding des not currently hatestenan4 that it is my rtsponsibiliey eco notify eche--
dos itresponsibility
«Fupbm of eh<xquircmemi which must be'mee pdond iishance of a Cevifcat4 bf
'�y: • � '' � �" '""
Signature of ApplicantDale
Al] roof coverings to be Class "B” or better' .
perp umarixalagent ' -,„�.,. ate
.
. ._•. �.... ...,. .. � -' � OFFICE