00120045 CI TY OF
BUILDING PERMIT CONTRACTOR INFORMATION:
BIIILDINGA6_f115: S fANIAU AV PCRMI INU.00I.G0PJ45
OWNER'SNq."11 NEE CLIFFORD E AND PATF ICIA - APPLICAIIOJ RI&'/._Ol't0
1'HONC: SAM'I'ARY NO, CONTROL NO.
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-'UD[:C'/IiN(1INI'IZR: BUILDING PERMIT'INFO
O O BLDG ELECT' PLUMB MECH
H 2 1 ICENSI DCONTRACTDH 4 DI CI ARAf111N Job Descrl tion
E z In I I,'cby X ll r,drat I t hucised lata. provisions of C:npler 9(commencing encing P
whhsection nxxn td D. ..n�t 3 m the moi(,,ram Profesi..nxCo1c.and gay License EXISTING TO TORN
=y .'4i is in lull b,rec anJad]c 1. �.(� /J I�Ij (�/
C 6 Littna CL]sa (oCTs_.(7 Lic. Lam.
y C L D li:>•o C'admcltn - —
u 5 m ASCII[]LCl"S DECLAI
t I unda%taal lay"Ions shall be used us puhllc cauuls
uut
i 6 p p Ltccn d l fc, I -
% OWNER-BUILDER DECLARATION
\TION /
a.x R I hereby all that 1 extrapt fn Ih Contractor's I' Law fill the j
Edlaw b (\ ea 70315 H s unit Prole-011S CJ Any city or'wnly
2 0 wolhes,marv,aornail I I 'It p 1 E,uor armi,la,yonulare
es. ago Pit...or in,t:air ol:rtcyurc lhsapptaa rl Lich pcamitt file ti-,maimacmenr
ma he is licensed pursuant m the arnowuroof rbc Conrm,ae,Licenm law(Chapr,9 Sq, Fl. Floor Area ala,
(comntoncinBwhhSwllnn]o0tuaf Division 30 the Bust..and Pr afasstom Cartel
or that he is exempt thenimnh and the Faris ea rbc alleged exemption.Any viululino
of Scctiun 9031.5 by any uPdwan.font Per inil ahjcele rdaapp wi I eh a-d penalty �y��'mn
of not more than live Hundied dolmas 0550(1. ARN St;dlehr4'7. 00 Occupancy Type
01.as owner of the progeny,or any employes with wages as their sole compensation. J J�
will do the work,and the structure is not intended or o0hred for sale(Sec.]IPJ.
Ll Less;%ad ProfescionsCode:'File Commour',tdcahxe Law den trot apply „ an "'05 — FRA
kyuired Inspections
orId progeny Who hulas or ilo,noves mere.....and who docs such work hilnsar 3
through his own employee%,provided 1bn.such improvements are nor intended nr 3p� — INSULATION
ollered far sale.II,hoaxlo r,the building or imrmvement is sold within one year of
imhmplwiah.the owner-badder will lime the much of moving that he did not build of 601 — ROOF TEAR OFF
prove In,P.",c or,me.)-
01."awn"W,ba 1 - 60P2 — ROOF PLY1400D NAZI_
eny,inn mclu.ivuly.d 11"actin,wineme EIhe Connector
(easelaweue,.,i(ippltSee om4.Bu.dhe%%aroerhew io Come nm co,dium,t` 603 — ROOF BATTENS
License law dews nor opPly m an nx'nct a(Wnpeny who twilda Lir improv..Nercnn.
and who commas for such project%with a nmlice-
ed liceed pursuant ro the E04 — ROOF IN—PROGRESS
Cl morou's License Law.
❑Ian e%cn.pl under See. ,D R I'C fur rhixreason
Owner Dae
WORKHR'S COMPENISATION DECLARATION
I hereby affirm under penalty of perjury nuc of rhe following declamlina,.
Ll 1 have and will lutintain a Cceifiwme of Consent in sdbinsurt for Worker's
Con,penmrlon, as Intvided for by Section 3900 of the Labor Code, far the
stiff nrmuncc of the work for which this .it is i%sucd.
❑I have and will lnoincein Worker',,Compcnxadon Insumncu,as required by Section
3701)at rhe Labor'Cndc,lot the palivmanw al'tbc wad fur which Nis noil is ,
issa 'orkers Comrenction In,sumnce cacti r and
Poll number arse:
Carricr;wt_�jJ�`�//{{��..�A�Tnlicy Na:
CERfI11CA'f16N Olr MITION IBOKIiHS'
C0xIPENSADDN INSURANCE
(This w1lion need.,it be cainplmcd Urhe Permit is lin one handled dollars
($100)or licks.)
1 certify he,in he performance of the walk Nr which t1.is pemit is issued,1 '
dell all employ airy pmon in any nmmner%o as to hcaons suh,icct e,the Workers' -
Conynpwrinn Law,al'C:lifornia.Date
Applicant
NOTICE*10 APPLICANT.I1:after nuking this Ced icurc of Fla,diption,you should
become object to rhe Worker's Comgensaiion provision of the Labor Code,you must
Q O fnnhwirll comply with such too,kions or this lernhiI shall be dremcd revoked.
L
F
In CONS'eHis a ION com1.ENDING AGENCY
> I hereby f which rhe there w..ad(Sinn lending agency for he gerinmh:mw
Lethe wink ror which this germit is issued(Sec?(09.Civ.C.)
0. Q Ixndcr'x Name
Q z I<nJcrsAdalrCF,
U Q 1 cenify Nor I have mad this application and stare that rhe above infornmtion is
fi [r correct.1 agree to comply with all city and county ardihenecs and state lawn mains
to building construction.and hereby amhoriie ourewmarives ofthis city to emcr upon
LI; the ah f n J proNdy for' .I 'tin marrows
�y Ga (W)agree ill save.indcornity andk I' vtheC1y fC p l ugn"o, '
.y ZI hahill' j Jy r......t J I "ENIE101 am,in any way clote against slid
UZ City in convgaence of the granting olthisl trout.
SOUHCANTUN UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ISSUE y: Date lJ
Signhmm of Aim ieantlCamraeanr Date Rc-rAAS
HAZARDOUS MATERIALS IIISCLo SUR17
Willrhe applicant in future binkins wcupanl ,arc or handle hazadaws mammal Type of Roof
as defined by rhe Cupedina Mmucilul Cali Chapter 9.12 and the Hiculth and Safety
Colic.Section 25532(a)'t
0Yes . 0 N All roofs shall be inspected prior to any roofing material being installed.,,
Will the applicant orfuture haildingoctalsoumcequipment ordevices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emir hvarsom cif contaminants a,dctined by the Imy Area Air Quality Mdnagmnena
Diaraerr all new materials for inspection. Applicant understands and will comply with
°van ID No all non-point source regulations.
I have trod it,hmardnux lu rend,reyuincoccas under ChiPlc,6.95 ol'the
California Ifir M Surety Cade.Seciums 25505.25533 and 25534.1 undcrntand that
ifthe building does nntcumnrly bane a mnam.that it inmy no,amibility ionmifythc
occupant at the mquirnaents which must be mat prior to issuance of a Ccnilicmc of O �_
OeCustany' Signature o Applicant Date
Ownerar unbowed agent Dae All roof coverings to be Class `B” or better
OFFICE