01050069BUILDING ADDRESS'.
NAME:
IYfOPI�
�O C ARCHITECT/liNGIVNIVER
'U
yzd
n i LICENSED CON'TRACTOR'S DECLARATION
0z Ilmmny,d Brnrahan 1:111) llrenwvl under pmvnina of Clan"', 9(am.nrencing
�yF with Sttliuu7001hor Oivia!nn Sol lac Busincv's'und l'ndennians Codc. and myliccna
qq ,fall 1111-1 an I clGxv
5 x L a Lm aeme Crus je.0 '
,a,f' O S a' Data Cnnlmaor
W3 -v ARCHI I EC 1'S DECLARATION
1 undersand my Plan, Quell be road a, public rtrmds
re
i p O 1_'menseel Prola-mo d
as OWNER BUILDER DOCLAKA9'ION
tyi I reecho afflln than I apt fmnI a
Are Con;mc¢ns Lensa Law It,, he
Z a following morin. (Scninn 703119 eB nines and Pndc,,ion,c Cool Any city 1)r canny
i z e which requlms a permll ,n a,nsaun, alter, in,pa 11. Jemolieh, or repmr any %vucture
dam onorm Its i%smmce,abs rouninno the applicant fur such rental I,, Ile a Oared amrmem
that he is licensed pm anuo 0e provisions of, mt
he Cractrre
'% License Le. (Chapter 9
On
coon, 11awi(h Stheatia"Npofhe brai,her the Business wand PrnfAr,1QCndc)
or Shutes n cacnlpt tbeminwr an;l the ands her Ice alleged cxemplinn ny l penaun
al' Scams ](q 5 iv any dood am lar a pemm wnju'n Ilea applicant unit coil penalty
of rim mnrony�ata five nnlldroJ Jnllar. tsswn.
Yin pili cr of ilea prnpcny. Or my clnployre, with wages to, their sole cnlnpansa ion.
will do the wink, and the .gmclure is not intended Or Otorad for sale ISce. 7044,
Business and Iforssions Codc. I he Contractor's Iacmlsc Law dura nor apply In an
::,.:Ic
N Prnpo, Who bullus O undrapes thcas+n, and who Anel Inch work hilnsdf
tNOugh In. awn ; y -,Io,,, pct vakd arm lath unpr tot it ended ..
honed letlateII: howevn, 1111 hnuding Or in...... Ince( so avid writhin orae ywr Ot
nnnplln totutowmr-hailder w.It have [tic burden of droving than hedad ant build or
irwar pnrpn,Ie el Ivle.l.
r ar Gcanaro run;fa taro w
im...no the pct Jan (Seel 7fN4, Bnsinear
sr and P...l'c.. an, Coot I he C...1.,'Q
LncaLawdr, n4 applyro auowncr nfprvpnly who frills or ngnt000 thernm,
Ind who cOn rect. Or such pnyccu will a unu,anogsl licnlud Pasant ,o the
Contractor's I.toonse Law.
❑lu 1),p; under Ser . 13 aft P C lot drip rmson
OwneUmc
WORKE 'ti f)'IiNSA'f10N UIiCLARATION
I herehy allrml under I Qtly OI perjury a .. ad Us lolluwmp Jeclarn(ione:
• ❑ 1 rove anJ will mvimxida ClaiGcune of Consnu m toll=nsurc for Worker's
Curnpmlxa;Ian, u% ProvIAcA fur M1y Secninn 3)00 of She Lvaar Cede, for the
perlbrnwncc of the work lin which trip 1-11111 n issued.
❑ 1 have:md ell11 reande in Will kin I Coulpmwamn IDIII Ounce, a can Proof by Section
3700 lid the tsrbar Codc, for are pe,don Tana, of tlm work too which alis 1cr nn n
,sued. My Walker's Conlpen.aunn Insurance carrier md Policy n eaher fru
Curril:_ Policy Na:
CERTIPICATION OP EXEMPTION PROM WORKERS'
COMPIiNS,M'ION INSURANCE:
('CruIcclirsiW 1).,Or nw 1, O4,knel tithe puimlt is he or died dollars
f$Ilq) 1)r ILLI
I eerily tire( in the perfnrmnnee of the wurls liar which Iris plotter Is issued, 1
shall tri rnl0loy any tarn In say manner eo a, e, nc ume st pal ria he Wader,
Compensation Lawn of Cabling, I Dom
Apvhranl
NOT WE'10 APPI.ICAN'I" IL earl nmklng his Glur,atc Of H-1,1 ,you should
an: a, sobKa sidle, Won kn's Connote... pre Its of the Lana: Gide. you ton,
O fonhwi@m(s
comply wiill such Ida ane, Orahls notion; shall be decnned revoked.
Z
G'I cn Chat theRUCr1UN [.ENDING n AGENCY
�iIhercby al fin Nan... It
lcndangagrncy fur the Pcrfonwncc
Un"fire work tor w'hlch Ihil pernun n n%uaJ ISee. 91197. Cie. C.)
G Q Lender's NOnm
� Z Lender's AJArms
L) O 1 army Nm I have read One al, ,kation seal anile that the adwe inrormafion is
Lis H c1 dere(. I sgru: In comply wilh all city elm county ordinance, and suite laws Mail,
O L)
on
ding erns;n.nit and hereby arhmdre mpmemalwOol' this city in color upon
,hc cleave n, pr,r y fa, inspcllnn ptrpa.cs
F,; Qtr (We, agree,n nope. mddeorf, it keep hannla,, the City rl Cnpnlina .,ruOr
fO [.,bird s, judgmcno" coos and <xp<nacs whrsh tory n may day :: «lie a"'ma Ise.
V z
City or .cqucnre(11 the grumiag Of (Into loci ran,
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL. NON -POINT
SOURCE REGULATIONS.
Signoune uI Aprl'marAeOmruwv DNc
HAZARDOUS MATERIALS DISCLOSURE
N'M ;Irc.nPhLavm lir Iaava holding ean,ryml Imre lir ),ndle IumNom nlamn:d
as de0ned by the Cnprn!nu I'lwdcipal Code Ch c,1 9.12, and tun Health and Saiay
Code, Sea 125572(x)!
❑ Yes ❑ No
Will In, applicant lir fauna building occupant use eyuipmem lir device%which
nil ha,eWOn. anal a .Hemi ouun us dunned by he Bay Area Air Quallly Manager em
Uidnn.,
❑V'c El No,
I have read Lha harmdous Inuachals,eyui;raten' One C'hupe, 695 01 the
Calinunia i lea(h k Safety Code. Soalarr s 255115, 25559 and 25534. I undemmnd that
if the building does na(curreadyhaveamnam,;hat it is any resrnnsihilly I nolily the
Occupant of the mquircnmnk wh!ch must be mar prior u1 issuance .,f x Ceniticme Of
oarp,ncy.
PERMIT NO
1.1.050069
APPLICATION SUIT Dart L
• -05/07/-100] _
SANITARY NO. CONTROL NO.
BUILDING PhRM1'I' INFO
BLDG ELECT PLUMB Mi CH
I=1 CI t=1 IJ
Job Description
GAS LINE.',
Required Inspections
106 — SEWER & WATER
202 — UNDERFLOOR PLUMBING
301. — ROUGH PLUMBING
302 — TUB &- OR SHOWER
502,— FINAL PLUMBING ENERGY
506 — GAS TEST
507 — FINAL PLUMBING
FINALED
MAY 2 4 2001
BUILDING
Issued by:
Re -roofs
Type of Roof
Date `'
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, 1 agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant
OFFICE
Date
All roof coverings to be Class "13" or better