00110148CI TY OF
BUILDING mVISIONNOPERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO,
3 f
OWNER'S NAME:
r
I=T-V
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3390 PE
-
tPIJCA1ION21I3 DAfs
•
PHONE
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NTN I.N(1.
ARCHITECUENGINEER;
BUILDING PERMI'I'INFO
BLDG • ELECT PLUMB MECH
1=1 IJ I_ I
N I
LICENSED CORACI OR's DECLARKI'ION
Description
uch, an�I1.I
1 rrn Ww I urn Iieeo,cd underPmvr..mn, of Chap 1, 9lcmn.nuncing
.lob
with Section 700(yof Division 3 of the Hu,incw, and Profession, C,Je, and my license
is in full force, and cf feat.
Li Claw, I.ic.k
UN B-1 OCCUPANCY/TENANT IMPV '
Dam Commaor
ARCHITECT'S DECLARATION
)
I unMrmund my plan,.ha11 be mal u, public mmrin
_
1 /
Liccmd I'mlosional
OWNER-BUILDER DECLARATION
I hrnby allirm .tem I rut, emmpn to the Contrnelor', License Low fnr the
/7
folL,wing ressnn. (Section 7031.5. Endres, and Prolew.dom Code Any city or county
7
which regabea a Iseult n, aun,mom ager. out ..e. demolish. o, re'Fair any elm bee
plot to it,issuance,, stem reynirn the applicant Ibr,Jell pcountto IIIc a,ilmd lawnscon
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant in the Provisions nthe C,ntrectn'%Lian,eLaw (Chapter 9
(commencing with Section 7180 of Divwon 3 of the If a,inesw and Rafumiom' Code)
of Ira, he i, axcoin lherefnnn and the ha,i, lar the alleged esnncian. Any violmin I
of Section 7031.5 by any applicant or a permit subject, the applicant to a civil penalty
APN Number
Occupdfic e
of not more than five hundred dollar, ($300).
❑ 1, a, owner of the properly. or mry ennployec, with wage, a, their ole connpcmatinn.
.:rG sG
Inspections
will Jo the work, and the structure i, not intended or otmeed liter sale (Sec. 7144,
Bnsirmw:unl Prom"in I, Code 'File Contractor', License [.I,. Amos no. apply to aI'
qulred
r of prorcey Who bold, ,r Irupnrn Ihemm, and who docs such work himself
or through his own anpinyecs. provided that such improvemom am not intended or
101 —
FOUNDATION
mllcred for sale. If, however, the building or improvement is sold wimin one year of
nmPlul I,. me o,,I,,bnlldo, will hone 111. ho,dcn rel proving bar he did ion hudd or
improve
102 —
PIERS
fnr par Nwo of sale.).
01.1), owner of the wopetly.a,It exalu,ively contracting wilt bceu.ed connaclurs to
103 —
UFER
74. 1 tli and Probe... on, Cde:) The Contractor',
nnswcl he P.Put (Sol .14
License
1.04 —
REBAR
Law does not apply 1)) an owner of property, who huim, or improve, thcaon,
lout] who conmets for such project, wort a rmnma.nn,) litemed nm nam 1y. ion
105 —
ANCHOR BOLTS
Con.mcmrt IJeeme Irw.
❑1ameamnotualurSee , .BMPCfor this ¢awon
1.0E —
SEWER R WATER
Oxmer
202 —
UNDERFLOOR PLUMBING
wORKEIR'S COMPENSATION DECLARATION
- 203 —
UNDERFLOOR MECHANICAL
Ilncmhywrrinnandel pcnahyorperjmyons, (It the loBnwmgdeclarancou..
204 —
UNDERFLOOR FRAME
❑ 1 have and will nwi,naln a C.mbaate o! Cm.sent to weft-msmc fm 111
Cnrnpcn,ulion, a., provided by. by Semon 3701) of the Labor Code. lin one
205 —
UNDERFLOOR INSULATION
perli,mnancc of.hc xmd lin which this permit is i.4rN.
301 —
ROUGH PLUMBING
❑Ile,caudwiule,force,a,recuie,dhySecdml
3700 of he Labor Code. for he Ihe,rnmmmm of the work to which this permit its
302 —
TUB & OR SHOWER
is.woed. My Workers CJmlhemmlon Insurance .aria and Policy number are:
-
303 —
ROUGH MECHANICAL
Carie. Peicyan.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
304 —
ROUGH ELECTRICAL
GOMp1iNS SIIHANCI-
ATION IN
305 —
FRAME
(This.anion need not W completed if the permit i. for one hundred dollar,
306 —
HOLDOWNS
alas "Iles,.)
I of mat in he Perfomtance of the wok fm which this permit is i.wed. 1
307 —
INSULATION
.hall ion employ any person in any nn:nmer so :is to laconic subject to the Workers'
:
SHEETROCK
Compcn.ali.m Iuw, of Curfnmia, Dale
308-
Applicant
NOT' ICE' 10 APPLICAN'n If, after making this Certificate or licentious, you .should
309 —
EXTERIOR LATH
hecan.e,.bic,l ,, the Worker, Campee,udnn provisions of he Lubar Cole, you rnu,I
310 —
INTE_RIOR LATH
forthwith comply web such Provi,inn, or this ..it hall 1)e doubled menked.
CONS 'IRUCI'ION LENDING AGENCY
311 —
SCRATCH COAT
I hemby oohs mat mere is a mmm¢bnn Icndimg agency forme f orromnmme
313 —
ROOF NAIL
of the work for which his wool is issued (Sec. 3197, Civ. C.)
1cnJC, N"a`
NhAddress
501 —
FINAL ELECTRICAL' ENERGY
lander
502 —
FINAL PLUMBING ENERGY'
I unify1)h:rtl has, readfirr,uppna:.tim.....I icle11hat le above information i,
mct.Iagree mcomply wihall .... ... de,,onlytubmamcsand sm1vlaws totaling
Wilding
503 —
FINAL MECHANICAL ENERGY
construction, and hereby mulaoriw representative.% of his.hy matter aloha
marleor-nth:nam...Iluo,cny for lnw,ectio.purivocs.
50A —
FINAL BUILDING ENERGY
(We) name to aavx, indoor ty rola keen la...tess the City of caperti agairuI
liabilities, judgments, cnsn ami exPensas which may in any way, accrue again• said
505 —
FINAL ELECTRICAL
City in or,cyucnac of the grunting if his permit.
ND RSTANDSANDWillCOMPLYWI'fitALI.NON-POINT
APPLICANTUNDERSTANDS
Issued by: SOFs —
GAS TEST Date
Signore, of APpllcwo/0 actor' Doe
—PLUMbINU
Re-roofs
HAZARDOUS MAT ERIALS
508 —
FINAL MECHANICAL
Will the epplicaut 1)r future building racap:m..tore 1)r Waage humadom material
Type of Roof
.. defined by 1111 Cupcoloo Mameip:d Code. Chancel 9,12, and the Ileahh and Safer
509 —
FINAL G RADE_
Code. Seclinn 255320):'
❑Ye\ 0N
All roofs shrill it aspectFdlH14
'
toFih j-"riltVl rl'naterial being installed.
Will the aPphcammfuture building occupantuse cminipmen.ordo%ice.which
If a roof is installed wilh6tifINLoblflldBlgLEinWa(F
IEr, I agree to remove
mat h t,ardous air cnntamire nn aw defimd by he Bay Arca Air enmity M.im,coem
Own,,?
all new materials for inspection.
Applicant understands and will comply with
❑ve, 0N
all non-point source regulations.
I have read Cho- hu ardon.s nmterialy requirements undo Chapter 0.95 of the
Cobb omen. I Icullh k Safe,y Code, Seen iun, 25515, 255331 d 25534, 1 undcr',tand mm
ifhe Wilding dmos no. aurceotly have a comm, that it i, my re,p.m,ihility,o no.ify he
mcupamt of the retlulrennrnts which mist W met prior in issuance of a Certificate of
Occupmcy.
Signature of Applicant
Date
All roof coverings to be Class- "B" or better
ownurormnhmi,edagent Dore
OFFICE