00100201 cl OFc ONNo
BUILDING DIVISION
IVISIPERMIT CONTRACTOR INFORMATION:
of UANG ADDF/SS: PERMIT NO.
OW'NER'S N h s: APPLICATION SUB DATI
7
\ RINE: ' ) \ SANrI'ARY NO. C NTRI)L NO.
aoARCIII'IECIIENOINECR: (408) 371i E73 i BUILDING PERMIT INTO
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z y LICCNSfI a CONTRACnderr DIiCI.AaCat Job Description
_ herebysmell ivi1tun octal,Runderp and
Propar r,Code.an,]
¢ow_yu9 with lotrne1and nfDly an 3ofMu Pus,nuss and Pml'ewona Gyle.and myliee
Yf; is in liJl force and dlcct.i,i � n
oa`u Liceme Class Lla.k FURNACE 8.' CONDENSER CHANGEOUT '
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Data Contractor
a
t-El O ARCIII'PECf'S DECLARATION
g 1 amlcotind my plane,hull W oral as public moll
M all
to p�O Licensed Prom"imell
OWNER-BUILDER DECLARATION
1 herehy affirm don I am exempt from the Camnemr's Lic m 1,IWw far,he '
H Z following mown.ISemion 7031.5.Business and Ploessions Codd:Any city or county
al S C which menial a peanut m conawa,alter,improve,demolish.or repair any%fracture
aiprim
orm its issuance,also forums the applteam for such honor to bit le a signed statement
— Ihalheislicensed pursuaotothe prnvi%ism, the eummemr.LlcennLaw(Chapter 9 Sq. Ft. Floor Area Valuation
(commm� cing will Sectim 7mX0 of Division 3 of the post at and Pmtmsion,Coca) -
or than he I%eanapt therst'mm anti the moi,rot the alleged exem,pt]on.Any violation
f Seed 17031.5 by any applicant or a pants%object,the a,dicanllo„dvll penalty
of mthan live hmailed doOhw($500). APN Number - - - occupancy'T pe
❑Las owner ill'die pmpaty,o,ate employees wit],wogs,as mete,lc ampc
, nsaaon,
will Ail the work.:oW the structure is no,Intended of o(i lin sole fiat.7044. .aG.r.J..l
Bmme.,amt Proc,alon.Code:'rne Cal lInctnr.Liecne Law does an appy,k an - equired Inspections
tiser of pmpcny Who builds or improves,hemnn,and who dins such work himself
t though his own employees.provided that such improvemenn um nal intended or
soled file sale.If,however.the building or improvement is sold within one year of 303 — ROUGH MECHANICAL
completion.the saiaptimiAer will have the burden of proving that he did not build or '04 — P,000H ELECTRICAL
impose for purple of sale.). .,
01.as mvner of property,am ennnsively contracting with licensed contractor,m 505 — FINAL ELECTRICAL
Lname, lie police,(sec.7044, 3-i e,,and Pmfe,siam Code.)me Contractor, 50B — FINAL MECHANI CRL
ice se L, din no,apply to an owner of property who builds or ilnprn es,hereon,
and whit concoct,for such projects with a enmmakr(x) licensed pursuant u,the
Contractor's License I,uw.
❑I tun exempt under Sec. .1{k P C for this reason
Owner Dane /
WORKER SCOMPENSAf10N DECLARA9'ION
1 nochy alliin,under'molly of pcijay me of life following declurniom:
J I have and will maintain o Cenilicum of Consent u, adGinsnm lin Worker's
Compmua,ion, as provided fur by Semon 37101 of ,he, labr Code. fill ,he
perfannmisc of the work for which this Kraft is issued. O
❑1 have and will maintain Worker's Compensation Insurance,as required by Section Q
3910 of the I.abr Code,for,he performance of the work for which this permit is
ssuW.My Workers Compensation Insulae carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATION OF ILCEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be,completed if the permit is for one hundred dollars
($101)or Ills.) -
I certify that in the performance of the work 1mwhich this per nil I%issued.1
,hail not....ploy allno
y veIn any manna,eo as I,.become,.hjc,l h,life .Or,
Cmnpeasation Laws of Cdifbrnla.Dale
A,lanol
bill ICH 10 APPLICANT If:alter making la,Ceniticate of l:seuplivn,you should
bl'abject u,the Worker'%Compcn,miou provisions of the[,alas Cmle.you mum
Q O fonhwilh cotply with,tall prookien,o,this pemih%hall bedecnted,evoked.
F ` CONSTRUCTION LENDING AGENCY
I thereby anion that there is a ctm„mclion lending agency for life Nifinrmence
D.1 of the work for which this permit I%issued(Sea.3097,Civ.C.)
0. Q Lander',Name
Z Isnde,`,ABdma
V Q I cotify thin l have mad this application and same Mathe above information is
confect.I agree to comply with all city and county ordinances and.state laws minting -
V hi haiWing con„mnice,and hamby vulhorim representative,of this city to enter upon
he above-cocnumnd propufly far Inspection puraises.
�}y y
(We)opera,sate,indemnify sad keep mmnlm,she Cay of Culnnino agaimt
F. y liabilities,judgment,......is and expenses which may in any way accrue against said
V z City ln.m.,egten,c of file gnmir,of Mi,permit.
APPLICAN'1'UNDIiRSI'ANDSANDWILI.COMI'I.YWI'II1AI.I,NON-POINT Issued by: Date
SOURCE REG4LATIONS, y'
SignamlcofAppH.uaJCum,amor Dale, Re-roofs '
UALARDOUS MA9ERIALS DISCLOSURE .
Will flee appllcan,or future building Icn,paal%ton or loathe haotNom m:nelal Type of Roof
as defined by the C'u,eAno Municipal Code.chapter 9.12.and the fleahh and Safety
Calc,Section 25532007
O Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the apphcantorfuture building occupanuse equipment ordeviceswhich If a roof is installed without first obtaining an inspection, 1 agree to remove
mit hamrdn i%air comaminam,as defined by the Bay Area Air Quality Management
tarter. all new materials forinspection. Applicant understands and will comply with
0Yes 0 N all non-point source regulations. ,
I have read,he haeardot,muterioh requimnnnts muter Chapter 6.95 of the
GdifLmia Ileahh Sc Safety Carle.Sections 25505,2553.1 and 25534.1 understand that
d Oce building Mn,nut turmoil-baso if tenant,that i,i,my responsuality to roody,he,
Scapanl lit she requirement which mu„be anew Frit,,m esmmcc of it Certificate of
O"upancy.
Signature of Applicant ' Date
Owinc—ratm,mi,.ed..gem Diane All roof coverings to be Class "B” or better
OFFICE