01110024CITY
I B
CONTRACTOR INFORMATION:
DWG DIVISSIIONNO
BUILDING
BUILDING ADDRESS:
PERMIT NO.
10161 WESTERN DR
WINTER ROOFING INC
01110024
OWNER'S NAME:
APPLICATION SUB DATE
CHARLENE HON
151 WYANDOTTE DR
11/06/2001
PHONE:
SANITARY NO. CONTROL NO.
4083638052
Z ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o — U L
Z LICENSED CONTRACTOR'S DECLARATION
Job Description
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❑ 1 hereby affirm that I am licensed undo provisions of chapter 9 (comm enc
with Serrim,7100).1 Division 3°!the Bueincmand fax rae, n 0-915,
REROOF.
amrmlforee and efre1)
Lica
WOOD SHANGLESr INSTALL 1 T/O W / 2 OSB
License Cares _
Dar p
tis
& 40 YR. PRESIDENTIAL SHINGLES.
ARCHITECT 5 DECf DECLAR TI ,
1 understand my plans ,ball he used as public me
OLicensed Professional
OWNER -BUILDER DECLARATION
1 hereby infirm he 1 inn exemia front he Contractor's Licase Law for the
< follmving=ry (SZon 7031.5, amines, and Professions CMT. Any city or county
_
❑ wM1ich rtquirts a permit m conslruet, alter, improve, demolish, or repair any swmure
. to file a signed statement-
-prior issuance, also regwrcsthe applicant or such perms
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- thmheii,lianwdpursuanetolheprowsionsofOaContracmrsLicense law(Chopmr9
Sation 70fp) of Division J of the Busineu aM Professions CMe)
r� ++Sq. .�F'[gqF]oot'•Area:- '�SS Tt,
� •� � `r 1',: � It 1ty. 10" :
- anon
$ 6 7�#
(commcPcing with
or that he ie'exempt Nnrefrnnr and the basis for the allegai aemptlou. Any violation
1 kl. _ sN r \J Y A
at Sado. 7031.5 by any applicant for a permit subjects the applicant to a civil penalty'
.of not mom than Five hundred dollars (S500y-_, - -
35APM*tynbR
1:':'... Occupancy Type
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will -do'the work. and the swmurc is not intended or offered for sale (Sec. 70,1a, -
Business and Professions Code: The Comractor's License law does not apply Its an
305 - FRAME Required Inspections' -• ='f
owner of property Who builds or improves thco on, and who does such work himself
307 - INSULATION t
or through his own employees. that such improvements are not intended or
_ .._ .. ._---. ... ._..
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Wilding p meatnsalewthinnot
':aneMi r If. bow thewill
ROOF TEAR OFF ' '
build
i theowner-milder ill have the burden f proving Na he did not build or
iompl
mprove for purpose of sale.).
602 - ROOF PLYWOOD NAIL
--- -
O L as owner 4. . contracting with contractors m
pSov.
- L, t 'n � -.. .
e project71N4. Boorro 7 -he Co
_ onswntheproject(Sa.7toaow,neroandertywhionscMegThevestmcen,
604 -.ROOF IN-PROGRESS`:I,l. ..... .. t.
law doest not apply man owner of property who builds or improves thereon,
- and who
' ._and.wctor's !Low., projects with e.commnor(s) lianud.pursuam m.dm.
'- Convenors License Law. ...
License
❑lemesempt under Sed.' � '-'' �.B &PCfor this reason
..
itC l;
- Orna" � Date
- WORKER'S COMPENSATION DECLARATION
' Ihereby °M.under ,pimuih,of perjury one of the following declarations:
❑ 1 have and will maintain a Cent Beat a of Comcm to self -insure for Workcr's
O/
Compensation, as provided for by Section 37W of -the Labor Code, for the
_ performance of the work for which this perms is issued.
❑ 1 have and will maintain Worker's Comp osi din Insurance, as required by Section
37M of the Labor Code, fiir the performance of the work for which this permit is
.iisuM: MY Wo C pasadon lmirv¢e.carncr aM PalcY mber.arf✓
rs M
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Corf `F°I¢y No O'
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t.a�y ���,'� i�.', 11}:. T.', ai, twY•!yl,T-SI v'!k
. .1 iCERTIFICAT10N OFBXEMPI'ION FROM WORKERS',- I„
- ..SATION INSURANCE �'...'. ,.,
COMPEN _-
I;
Thm'u8ibn need not be completed if the permit is for one hundred dollars
� '• '1D'I i`I' il: Ciq' 1'1'., I_'7C
(5I W) or lass.)
which pe t ss d'1
Ic rtdyNtinthens
r
• s rl:•j C°Ii2Hl' '
any Persons m any manner so m Ip become sub)at to the Workers
in anacnM to
shall not anon
.Data..
Compensation Laws of Califomie„
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Applicant -,.. _
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NOTICE TO APPLICANT. If, after making this Certifcarc of Exemption. you should
NOTICE
become subject to the Worker'a Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
i
y"" CONSTRUCnON LENDING AGENCY'
1 hereby off rte that here is a communion lending agency for the performance'
""
_'
r of the work for which this permit is issued (See. 3097; Ci, C.)
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] -Landers Name'.•°•. ''-' .•.'.•." _ ,....._ .c_a ..a.
.... - _ _. ._.._._..._.. ..__......_ _ ._ ......__.:. .. .._ .__. _. .____.__.
Landers AJdress'
I certify that 1 have read this application and stoic Nat the above information is
camrose I simony comply with all city mW countPurdimrtcrs and since laws totaling
1. building cunsmuction; and hereby amlionte repa sentetives of this city to enter upon
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a[ the above-mentioned propenY for inspection p ox;. .. ,_
inyc fy 1, h he City Cupert
- - -
g. We 1. m save, t and Q teles, of no against
n liabilities dements, costs and espenxs ich may in any way accme against said
L City in dll srqucnce of the 'A.")t,of permit.
_APP" NT UNDERST- urlLivll'N'ALL NON-POIIPf"
Issued by:. .�. Date"
so E AT
i a, of ppbca - Date
RDOUS MATERIALS DISCLOSURE '
Re=roofs - -
G1
. Will the applicant fm Wilding occupant store or handl Intervalmaterial
r
Typeof Roof,as
fed by the Cuperi M ', pal CM Cb pt 9 12, e d the He Ith and Solely'
C c Sccton 25532(.)?,,ir -.41
.+% + e • ! 4 .• ,.
j.i,I -�A air i�'�j'r Ls 5'
J ,'i'
"Duca •❑Nn : ',
.e
Yl:a
All roofs shall be.inspected.prior to any.roofing.material being.installed._ .-.__...
:. win the applicant as future Wilding occupant use ctripment or devices which
If a roof is installed Without first obtaining an inspection; I'agree tdremove
em t M1 d s air cam m oars. a: defined by Ne Bay Aria Air Quality Management
.is ty
all new materials for inspec',n, Applicant understands and -will comply with -
_
0° b "r • ° No ; ..
all non- int source regu ons.
` IFI h - J'the h d muter q ms undei Chrovir 695 of Ne
Cel fo H ❑h & Saf ty CM Secdo 5505 25533 and 25534 1 understand Nat
if theWld d not currtn0yhis, e tthts mYres nsthrlry to notify the•-�%-
h be Cen !cele
acupam the equir entyvti ust ,nonce of a of
ria re of Applicant - - Date . -- - - - -
n
-Si . .- - -
All roof coverings to be Class "B" or better
a• ,� . aero
17A
OFFICE--
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