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CITY
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BUILDINGDIESIONO
NPERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
10210 STERN AVE.
HENRY LO
01100039
OWNER'S NAME:
APPLICATION SUB DATE
HENRY LO
10/08/2001
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description '
I hcrebyaFmn that l am licensed under provisions of Chapter 9 momYencing
Business ad essions Code, ad my license
with Section 7000)of Division 3 afthe BusinProf
NEW SERVICE ENTRANCE.P
is in full force and effect.
License Class Lic. a
Data Contractor
ARCHIIEC 'S DECLARATION
1 andenund my plans shall the used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirrin thin I an esemDt from the Convectors License taw for the
following reason (Section 7031.5. Business and Professions Code. Any tiny or county
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which quires a permit m com dict alter mprove demolish, or repair any svucmrc
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pricama, issuance alsorequvesthe.,[a , formahp unnumfil. vagrvd statement
----- -. _. _-. ......_ .. _....__...._ .. -
that he is licensed pummi l to rah prbvisions of the Commcmts License taw (Chapter 9
(commencing with Section 70001 of Division 3 of the Busthem sad Professions Code
{; Q. `S?3 �'l t: t�r8a^t.. tt •q• r-
7
Valuation
or that he is e9empt tmiaborrt and the basis for the alleged exemption. Any violation
• i l V t t r\ a a 1
+
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of notmomhanfvehundreddanars(s50h.
304'PN�H ELECTRI
Ali` Occupancy Type
❑I.mrof Ne property, or my employes with wages u their sake compensation.
will do the Work, and the structure is not intended or offered for sale (Sec. 7046.
• [tallness and Professions Coda The Contractor's License Lew does not apply to an
505 - FINAL E11 R11IC &Potions "
.as, of property Who builds or imroves Unmoor, oes on, and who dsuch work himself
or through his own employees. provided Nat such improvements are not intended or.
offered for role. IL however. the building or improvement is sold within one year of
,
completion she owner -builder will have the bode. of proving Nat he did not build or
mprov for purpose o nor.)
C
tl `,
. 2 owner of the property, sm exclusively contracting with licensed comvictora to
.. ..In tl��`•I�
construct On, project, (Sec. 7066, Business and Professtmrs Cade) The Contractor's
of pmny who builds or improves nM1ereon,
License does Law not apply m an owner pe
I
r5 1 etO ��
OCe
and who contracts for such projects with a contractors) s) licemed p....a, no N
.1 _
0Ci1 car am Licenselaw.
B&PCfor this
Olam strops under Sm.��
Owner 'I_
BUILDING
WORRA'SF COM�ATIONOCIAR/ION
1 hereby affirm under penalty of Perjury one of the following declarations:
O 1 have and will maintain a Cer ificatc of Conant w miff iname for Worker's
Compensation, as provided for by Section 3700 of the labor Code, for the
performance of the work for which this permit is issued.
01 have and will maintain Worker's Compensation Insuarice, sm acquired by Section
3700 of the labor Code, for the perfomunce of the work for which this pertot'is
issud M W kin, Ct pe m al vmnce cv rvntl Poly moolve, am:'
Cam����[[��A��ih� No.: 1 -
f \\'�•'t•}' �' e.� 1 ,! :'': bb rs 6 1 1t { . .
s✓ ' w
C=FCATION HF FXEMPf1ON FROM WORKERS I
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-1 . t I eY..:. t .' .. • • t . , i
COMPENSATION INSURANCE
•
(This section need nm Ce completed if the permit is for one hundred dollar
1" � {s - I" Is,l:'--
($10000rlem.)
t
I'cenif(( that in the performance of the work for which this permit is issued; 1
nc so asbecome
shall not employ any person in any manner subject to the Workers
.m
Compensation laws of California: Date ''
'Applicant
NOTICE TO APPLICANT. If, its, making his Cenificam of Exemption, you should
bamome subject to the Workers Compensation provisions of the tabor Code, you mutt
i
fouhwith comply with such provisions or this permit shell be deemed revoked.
t
— CONSTRUCTION LENDING AGENCYI
'I hereby aRtm that Nam is a gonamedion lending inertlyfor th6 pmfoimarce
" r
of she work to, which his permit is issued (Sec. 3097, Civ. C.)
Lender's Name'
Lender's Address - _
•- „ .
. I unify that I have read Nis application and sum Nm the above inflammation is
'
coupon. I ague N comply with all city and county ordinances and state laws relating
to building construction, and hereby 'authun a representatives of this city to enter upon
the above-memioncd profanity for inspection purposes.
(We) ague to serve, indemnify and keep harmless the City of CLpenino against
`
liabilities, judgments, costs and upenus which may in any way accrue agaimt mid
City in consequent f the firming of this permit. "
APPLICANT UNDERSTANDS AND WILL COMPLY WI ALL ON POINT
c
ISSned b Date
Y
g vp�
Si nRUWilRt�app0n o
HAZARDOUS MATERIALS DISCLOSURE
Reproofs
O./
orfuture'..
rcOharpmenarartlea 'aterial..
building m
applicanto s
baa Godo, occupant
., .:, . .
TYPe of Roof ..... ..._ `..._ _ ...
as definWi by the C 9.l and Ne Heald a.e Safety
r,. 1: i1.' ', r•
;a•'. iS p t4: asl. i'r: ,. :.. a.i
,.-All
Code.OYs 25532(a)'. ,. - ❑No' •'1 s?\:_.h..{i.i
•
;l
roofs shall be prior.to.any_roofing material being installed..
Will the applicant our future budding occupant use equipment or devices which
-inspected ,
If a roof is installed without first'obtaining an inspectidri','I agree'to remove
emit hamodouseir commoner's as defined by the Be, Area Air Quality Management
District?
all new materials for inspection. Applicant understands and will comply with
❑Yea, . - ❑rva
all non -point source regulations.
"1 have read the incursions materials mquircments under Chapter 6.95 of the
Califordie Health & Safety Code, Sections 25505.25533 and 25536. 1 understand that
if the building does not currently have a mmor;that a is ny rspensibilitym ramify the
,
occupant of the mquiremems which must h met pe'or to ismanum of a Ccnificete of
My.
-!/`y' I=` �" � I
(�n'
Signature of Applicant Date
All roof coverings to be Class `rB" or better
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cr or Announcedagem rte
6
OFFICE