01100018 CITY
I nDNGDpERTNO
BUILDING ONPERMIT INFORMATION:
FORMATION:
BUILDING ADDRESS: PERMIT NO,
11631 UPLAND WAY ROGER WANG 01100018
OWNER'S NAME: APPLICATION SUB DATE
ROGER WANG 10/02/2001
1 PHONE: SANITARY NO. CONTROL NO.
O ceZ ARCHITECTILNGINEER. dUILD PERMITINFO
IJ O❑O BLDG ELE PLUMB MECH
a i W r-1 'J LJ LJ
y a LICENSED CONTRACTOR'S DECLARATION Job Description
z_O 1 hcmby affirm that
1 am IittnxJ under provisions of Chapter 9 6ommcncing
mt-m withSection7")ofDivision3ofthe Business and ProfosionsCode,and mylicense TEMP POWER POLES .
is m fall fmce and effect.
s a Lacers¢Class Lie,0
O n U Dote Commuter
i 3 u.G ARCHITECT'S DECLARATION
'-O g 1 understand my plans shall be,used as public research,
t s p CO Licensed Professional
e OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
C Z a following reason.(Section 703 IS.Business and Fictitious Code:Any city or county $200
E x o which requires a permit m construct.ulrce improve,demolish,or repair any structure
aw t: priort t '. also cq e N applicant for such permit to file a signed succi am. _ _. _.. _ -......__.._-___—._.__.__.__._.
that
h rltt w
sed pursut the promons of Ne Conuectws License Law(Ch.d.9 f ,,,_.t �yyFF{{,, yy''.II����{{�gr•p�@a '+h Valuation
hemnmenc g with Section 700(1af Division 3 of he B cticess aril Professions Coda) C i—j Sas 3 MCA r'1'. v., 1 t ?,A I f-,:N
s:
or that he ii exempt ilhairefitortiC and the basis for the allegcJ esempdon.Any violmion
of Section 7031.5 by any apPlieam for a permit subjects the applicant to a civil penalty'
of bar rmre than five hundred dollars(3500). 10:�PN NyAK a' Occupancy Type
°1,as owner at the property,or my employees with wages as their sale compensation.
will do the .,it.and the stromure'is not amended or o0'ered for sale(Sec.70441: -
Busher;and Professions Craft:The Contmcmr's License Law does not apply to an Required Inspections`•'-
'
owns
r of pm,ny Who builds art immures Narmit.and who does such work himself
or through hr own employees.Provided that such plod is sol art not intended or
oRered f 1 If hos rl - w bu Id g p t Id ih n o Year of -
compll N nc bold illh cN<bN !pro gthat hcid tbudd or
'rep f cut 1<)
on,owner 10 Pmpcny lycontracting ithlicensed contractors to ..
construct thproject(S 7610 Business and Professions Code:)ThContractor.1
License Law gets not apply to an owner of property,who naiads or improves thereon.
_ wad who commus.for_such projects with a mmarlims)licamed pursuaal to Ne- _. �y y�_C
Contractors license Law.. .ALEO--
- emptorder Sae. ' r :e'kPCformlareason, FiN •,t•rpurr.
oda' �ARAzLl� OCT 15 2001
R ERS I'LNSATION DECLARATION
{. I hereby aRnn underspenalty of perjury one of Ne fm lowing decimations:
p ° 1 have aad'vill maintain'a'Cmific:it ofConsentIo self-inure for Workers BUILDING
eampcwtion. as novided for by Scceon 3700 of he Lmor Cade, for she_ �peRonllmlce of N'e won far whidt Nis permit is issued.
01 have and will niainialn Workei s Compensation Insurance,an required by Section
3700 m Ne'L.b,;,Cale,for the permormnce of the wmlr;for which this permit is
isamed.My Worl, iComproe,c, In....net carrier and PoGcynumber arc:'" _
tamer `f aN.e s A S'i`_Policy Nd ,-t. .sta,.7.,, . . l'1.
CERTIFICATION OF EXEMPTION FROM WORKERS" - t - • ' s 1:'`r4( ii.ts "1�4t Il s
r
.rP COMPENSATION INSURANCE,:
s mos wa snap nccd not bs'evinpleted if the Permit is for one hundred dollars
SIW)orlcc. ,,e nm .,. .�. .
, u i _
e...,...�...._ . .. _ _ . .._ _ ._. -
'aemploihmtjpe pc in "nmaria, orkf a.s. pe 'Its i.saeJ l ls:•t Lrt C llpe
shall en anon L wi of alt in any manner m as to bu6mc sublecttd Ne Wwlen
Coplicimktion la'1Califomie.'nam` ...' .'.
Agi
�'NOTICETOAPPLICAM:IL star making Nis,Cemificme of Exemption:you sM1amlJ °''
become subjectre the Worliat's Compensation p tours of the Labor Code:you rintiest
Q O forth ith ply with h provisions or thisI pe hall bed d evoked
CONSTRUCTION LCNDINGAGEkY
'� ' •' 1 he by affirn thindami,.c.nomert land,'ngg'ogmty f he perfommode
of Nc awls for wtiich this permius isaad(Sec.3097.Civ.CJ.
L Q —(war's Name _ _ _ -
_ z 12nAers Address" ,
U - I cmi fY Nat 1 have read this application and mute that he above information is,
-F correct.I agree to comply,viih all city'and county d' ret d state laws relining,
U to,he ma g sono' r ndh art N p e... en ofN tYt e err upon
,he bo t d p pen3 f De h Durpose
.F y 15rydg m sat d su'fY d Jeep harmle.die Ory f C pen agvmt
to I ati I t g ms e t d penin. which may in any way acme again..said
UZ City' oaqu nee of Neg i'gol Nis pe t /a O2 �/
,APP CANT UNDERSTANDS AND WILLCOMPLY WITH ALL NOYPOINT !I
so RCE ,u_LATIONs. . (, J' ,•+ �� z o Issued by: Date
_ igq canVcamr Da,r' ,.; " Re-roofs
HAZARDOUS MA rERIAL ISCLOSURE
W II Nc'ppbcam&f ture mildi.,occupied sam 6 aside hazard r mdmil Type of Roof `
as d fnW by theCupcn Municipal Cal Ch pt 9 12 and theHealth and Safety r o •-.1 r t1
Cade Section 25532(a)?,
OycOblrillfv,_ All roofs shall.be-inspected prior to.any-roofing.material being.installed.______-
Willeheupplicamrntumrebuiadingoccu Pan;useaquipmanlordevice,which If a roof isiifstalled'Vitt thoutfirstobtaining aninspection;'I'agree\[oremove
emit hazardous air mmamiwds as'depard by the Bay Arca'Air Quality Management
Diatdee all new materials for inspection. Applicant understands and_will comply with.-_
❑y, C. 9No ;r all non- oint source re ulations. .
have,read Ne hazard...nout.1 quiamenu'. chaptm 6.95 of the
C dmnu Health&Sareiy Cade;Sections 25505.35533 and 25534.1 understand Na
1tie buil ding doe no, .me ly hmxomnanr that it is my rtsponsibiliry to notify Ne - - , ,
'cuPa mcon�h uit here tP tin ane f CnEcde of -_ _
en c= `)' �'•- /C, Signature of Applicant Date
// All roof coverings to be Class"B"or better
[: Oancro Narixcd ng t, I }'
Data
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OFFICE - - -