00080107 CITY loFNG DPER'pNPERMIT
No CONTRACTOR INFORMATION:
BUILDING ADD BESS: PERMIT NO.
OWNER'S NA .. J I W b 1 H H H L 1 1 1 APPLICATIONSUB DAre
5KJIONS: SAN]t'ARYN . if 1 OPl'T>I.RNo.
BUILDING PI1IRMI'r INFO
C
Q C ARCHITIiCn1iNGINEIiH: 11 ELECT PLUMB MECH
O I-1 l_I I'J I-'I
F
l hat I a n liven d utid r pr DECLARATION '
o c l nerrny:nnirnn mm 1 ane Ecensm mnheer pr rex mcnapmr o a'nmmenrmg _ Job Description
lin H w with Sc l....]lNNp of Dlvisian?efthc ltusinasn d fesxinnx Crede,and my Nevose
cx 2: is in full force aurlltlec IIe� 'J
ow u I.iccn Class v 9 Lic.N -+ 9�[
Re.
cmn,r r — �J BUILT UP TO MODIFIED BITUMEN SYSTEM
ARCfII I'IfCI"5 1 .L. TI(1N /
C t-`n 1 uMccannJ shy plan.shall M usnl asp ¢retard,
o d¢i
e.i O Littnxed Pmfensinnal
u OWNI?I"-Bl from
D1ite Com'ION
w-w I hereby.diem onfle1 I. mann,from Inc Css4on% od :Any C Law for my
I-Z he
a following reams.(Section)O)m. 1,amedss and ot,derons Cade:Any city nr roomy
s H❑ price requires n permit tar cmmwe6 alma improve.h periiiit t or repair any smuawre
e�� theatre
it,isuwhee,ndsn requires lhu upplicum lornucM1 permino Be,ocI.nedmmement
ocomme bcenmd pSectio e�mepromi.tonsnr me the Busrc Ldenm l.uworct Codd) Sy. FL Floor Area alffii<V
lcommce ing 1%cwith Section 71n and
is lba on B of the legedeesand frroivar Any vi Crvon
nrthat
orix cum Pt,ary 11hand,he badsfor the alleged ppli,erwarou Any violation
of ma
703I,5 by any dr d doll lar;;laanhi,xuhjccs the tnPPlieum run civil pmudy
arum mare loam cmc hundred denary Asan. APN Number Occup' y e
❑1,as owner of the popeny.or my employees with wages as their sole cmmlrcrwhion,
will do,hc work,and the structwe Is not immndrd or nBned for sale(See.7014,
nosiness and Proresamrs Cole:The Conteri Liceme Law does not apply tin an ' aired Inspections
r of property Who milds w improves thereon,and who does such work himself
or monolith his own employees.promoted that such improvements are not intended or
alwwd to oats u',hawavnr,the bmilding or'nnmpn„merecnt is sold within enc year or 305 — FRAME
iompletion.the owrm-buiWer will have the burdenof proving that he did amt build or
mprov tier purpme of wlc.h 307 — INSULATION
❑I.ar(wamel1111 prap111y,nT cxll aNely emmmedmewim licrn.ed communes in 601 — ROOF TEAR OFF
construct the project(See 7044,Business.,at Prold,im I,Ccdc:)'I'hc Crearad'u", y .
License law deur mat,olyman oxncrefpmpeny who builds or improves thereon. 602 — ROOF PLYWOOD NAIL
and who commers for.such projects with a cantmcons)licensed porsuant ,,the
Ca an"b",Lierlhsm Law. 603 — ROOF BATTENS
Cl l ane cmmpl aadm Secs .Blit PC for d,i,ma,am 604 — ROOF IN—PROGRESS
Owner—D he
WOItKEH'S COMI'1,NSAUON DECLARATION
1 hereby affirm under penalty of perjury nue of the following doelarra mm:
J I have ;rod will mdntain m Califon,of Consent m self-insure fur Worker's _
Com,nounin. m pmridcd 6r by Section 3700 of the Lubar Code, fur the
performance of the work for which this remain is issued.
O 1 have and will;uuintuin Woder's Co;npemanlen Insurance.ss reynlred lay Section
170D of the Labor Coda for the perbrmance(it the work for which this per.",is
issued.bfy motion Imumnce carrier and Policy nun a/f�''7
Curr '1'nlicy NrvI . �rl l
Clifil'IFICAI]ON OP ENEMP'l ION FROM WORKERS'
COMPENSATION INSURANCE
('[his nccdwn aced not be complmcd it the Iuroth Is tar one hanrlred dollars -
IS I W)or los.) -
I ceniry that in the perfnnnence mf me work fee which this p[mail is issued.1
,Loll mot....ploy any ee,r it any nnanvcr see as u,bcar..e sabjrn as the W..kers'
Compensation laws,of Culilbmd.Oum
African
NOTICE TO APTTICAT41:If,after making this Cenircme of Exemption.)on should
hecomtc ret iumo,baW;..ker's Cnnhpenawimm prmvisinns of Inc Labor Code,yon nom
O O forthwith comply with such provisions or lois permit shall he deneed revoked.
tiCONSTRUCTION LENDING AGENCY
C > I hemhy at'Ibir that here is a comatruction lending agency tot the pnformmrce ,
of the weak for which this Iannit is issued(Sec.?INA,Civ.C.)
SQ Leno
t 's Name
Z Larder's Address _
I anify that i hamcwrd this applicator and sone it,.,the dive infonmuion is
correct.I agree u,comply with all city and county ordinances and state laws refining
O U to budmm
ding cstmn.met herehya'thoi.e representative,,ofthis city to enter upon ,
,heat c-mmniancal Tr 11 rmr imspelten pngmxes.
Ems., 11 (Wel agree Ill lose.Iademnlry and keep harmless the City of Cupcmino against
V liabilities,judgments costs and expenses svnich may in any way accrue against said
U .Zi City in consequence of the gmrdrg tar this perms.
APPLICANT UNDERSTANDS AN WI COMPLY WITH ALL NON-POINT Issued by: \ Dal
SOURCti kEG`UL=TIONS//�� � I �.�. � n. Y'
Sign' fAPPli,mmCh`rracm� _ '[�yl/�GL Data Re-roofs ,
HAZARDOUS MATP.RIAI.S DIICIAS RF.
Will the applicant nr firm building ootop:mt.amre or handle harallous nearnal Type of Roof
an defined by the Cupcmino Municipal Code.Chapter 9,12,and me Health sad Safe,y
Chile,Section 25592(a)7
0Ye, °No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building mccupantmcegsooner,nrdemicvswhich If a roof is installed without first obtaining an inspection, I agree to remove
mit weaNuus nir contatifinters as droned by the Pay Arco Air Quality Management
„ria,': all new materials for inspection. Applicant understands and will comply with
❑Yes 0 N all non-point source regulations.
1 have read the hueardom materials nquircmens under Chapter 6,95 of the -
CAW...nln I lnthh a saw"Conic.Sec,ians 25505,255.19 and 25534.1 undewand I I
iI the building does not emend,nine a waial.that it is my resptmsioliy ho notify
occupant of the requirements which must be met prior to issuance of a Certificate of
"clopanry' fgnature of Applicant Date
ra tn-�a a��n —✓ -
Date All roof coverings to be Class"B" or better