01100165 C1TYOFCUPERTlN0i' x 1 I
smLnwc urvtstov .''.PERMIT '.., •'•:: j CONTRACTOR INFORMATION:
•,.•BUILDINGADDRESS _ . ' .: " I PERMRNO,.
10516• "
WHITNEY, WY 'BUDGET 'PLUMBING 01100165
:.: OWNEi__ ..�. -..�,'...-. .y '__,__•„-•_ { -_- _ _ __. _ APPLICATIONSUBDATE __ -___ __, ,_-_
_
RIOPEIOPEL DAVID P .r `. 28635;.ROANOKE" ST :: . : '10%31/2001
r -
PHONE( •- - - "(510) 264-1113 SANITARY NO. CONTROL NO.
f
E O O ARCHITEC(ENGINEER: BUILDING PERMIT INFO
6 BLDG ELECT PLUMB MF,CH
6'<
H i LICENSED CONTRACTOR'S DECLARATION Job Dt
iZ4p IhdebyoFllimthmIton licensed unic,,rovi .m.ofChapter 9(commencing REPLACE WATER HEATEeSRIC�p�
o,t with Section IM)of Division 3 of the Business and Profssam,Code.md my license ���.® -
is In full force and effect.
s s a License Class Lic.a
g o� Dae S DELLA JUL 2 5 200
ARCHITECT'S DECLARATION 2
9< .I udcrsmnd my plans shall be uud as public records
r
i oo LiccnvedProfessionalBUILDI
2 c LL OWNER-BUILDER DECLARATION N
ao-m 1 hrcb
rY affnn that 1 am a pt fromto Contractor's W Law for the C.7/T
F zfulbwmg.. (Sect ]031 5 B - tl Rot Cade Any 'rycounty , s t ,.. I •i -
which requites a permit to construct,alter,improve,dI'h pa y structure •'' "' :"i
wm •.proarmin an,asive,also requiresthe applicantr h Permitil file a signed nate i_ 11 1 s� i il,l. >y.vsva ._,
that h2 igl -used pursuehl io the pr on ofth,C -Contractors Lire Law(chapt 9 f.,, 1 S�g'3,Rea,•Fml,Givsr/ Valuation
(cbromernJitA wish Section 7M)of Division 7 f theB smcuoad Professions Cod)
or thi he is exempt therefrom and the basu'for tar ellegd exempt My violation
of Sectinrcthan five hundred dollars
or d peimirsubjects the,applicant to weevil penaltry' _ _.-_.........
..
of Section than
n iv any applicant for en:a:, PN,NI I--L-..PLUMBIN ,ENERGY�ccup5ricyTyPe.
01 ma of the p pent my mplu) with g their salcemirissauon. -
tFdo the rk d the of to ded' E red for'sale(Sec,%0.16, -
Ras n. d P r xia . c i Th Comr t LiLaw does rud ply m an. . _.__.._._-5 0.7_.-_.._F.INAL_.PIR �,Mspections I: .-..._?:'`---,_._--------- --- ------
owner of properly Wbo nouns or improve.mereon and who it.such work himself _
or InrouPgh his awa employees.provided that such improvements au not imeMee m _ _. - _ _-.
rnffimL foe mle:If,however,the building of Improvement a sold within ane year of-- -- -- -- --- - ---- - .t�.t
completion,the owner-builder will have the burden of proving that he did not build or -
improve for purpose of sale.).
• Q 1,az owner of then,em exclusively connecting with licensed contractors m - -�-- _---'-- --�—_' ---- ------- -
pY yarn gwl ..s r_0. •' i..s
construct the parsed(Sec.
(SecSec.]054,Business and Pity%nob Codi The improves
thereon,
'! '" License Low tae not apply m an owner th properly who builds m improves thereon, - - -
' .andwhu.wniicensfor.such. r.jns with.e wnaanor(s licenud. s.to.the. .._.._ ___. __.... ..._-___... . .__.... _. ..__ _.....1 .
Contrutofs License hew. .I,
❑I am exempt under Sec. .B&PCfor this
Owner' .. . .Dam '•• tip .• 'Ci ..
"- WORKER'S COMPENSATION DECLARATION
I hereby mli.under penalty of perjury one of the following deelared...: '
❑ 1 have and 'will'niainmin'a Certificate of Conseni'to self-insum for Worker's r
Compensation. as provided for by Section 3]00 of the labor Code, for the
pMammnee of the work for which this permit is issued.
❑1 have mdl'w ll maim W tier's C.in oI atm lnstomil q f ired by Section , ,. . s i .I 'it: h)' ".I t
3],10 f th LaborCede f theer
pformance of the work for hien Illi mod,is .t s'-` �, .. ,._
_ _issud MY W kd Compe u n.lmum ex_and Pol cy. mbcr sa.i...,•... -.-W..-• -s :• ef.�•1=s?Y":"'-'._ _ _ _ _ - __ _
Cater d ..
144", .4r :LifflucyN .. _ ( !' tYu i 9" 1�) 1{ -
1' CERfIFICATION OF EXEMPTION FROM WORKGRB J :. it, _•a�. Y tl,,,.,� R a: l"1..s`. Y. �..,
Hi. COMPLN$ATION INSURMCE:
1s a ('Ih¢section need obef cnmplcud'f theperm t is for ox hundred dollars
c., •.:.. :..
I'=that n the pert rare ce of the k for-h i'th s pcnn oil rsxud,l 4.f-vIJ_... __
shall not employ any Person n tiny manner sq,,to become b) t to the Workcrrs _ .__.____.._. _ __ ._-_ _.. - _. __._.....,.____... . - -__.._ ..
,. - - .. _'
:. Cmnpc aI on'.Laws of Cailfom a:Dem','
NOTICE10APPLICANT If eBcr making chis C<nificme of Exempt on you should .�s" -
Q Qttbublmt th eWorkers Compensation Provisions ofthIabo Code you amiss
me vfairtWith comply with such provisions or this permit shall the desmadi revoked.
r
-y 111 n "" 'CONSTRUCTION LENDING'AGENCY' r
Fv I hemby am.that there I,'.combustion lend ngtimey f the pedorriurice -
4•'.� orth k for which th Perm t issued S 309] C' C) * 'eA yy
W''Q -).ender a * .• ,r_ ..
Lm& Add e 5- -
,,, 1 cent,that I have read this application od state tom the above information is
Wt
kTaF cone t 1 comply ih all city and unry o❑ es tere acend slaws mlmine - -•- -- - --- - ----_.. _.
OFto g mactib mdh by dutom p .etives of thixciiym enter upon t
>_W fficalove-mentioned prority for inspeelion purposes // �y\/
JA
p, (We)agree to use,indemnify and kap harmltti Ne Cty Weaa emiirw agunst - - --�JQ C/,(yI,�` - L/'
pCPP LICANTUNDofthe gDSA,. 119,E COMPLY Z) liabilities,judgments.em.am ex,me,is him may in my wsyraarve ageinsi xtid
t WITH ALL NON-POINT"
.. ,,., Issuedby: - ' - - Date -
sigparure of Apprranticantraem.• " . •.,mate. Re-roofs'- • . _ .. .
I °HAPARUOUS'MATLRIALS DISCLOSURE - - - -
W 0 the ppllcant d fat ' building occuipam store or handle na ehdoru amentil :Type of Roof"" - ,_. .. - - -. .•_.
as blind bYih<CLpcm o M m- I Code Ch pt 9 12 said the Health tab Sn(ry
Cdd Saran 25532fa1{ 1 .iop
'
i ❑v ',I . ,� ❑Nd.. �i, i r't-: .: . - All roofs shall be.inspected prior to.any roofing.material being installed...
+' WtINe_pp'"at r t wildiing pa tuseegapmentordeviceswhich If a roof is installed without first obtaining an inspection; l agiee.to remove
cm t hvadous r contaminants az debned by the Buy Arra Air Qusbty Management inspection.
DstiietT - ._ all new materials for-ins ection.,,Applican[understands,and will comply with
❑We,l 1 -pN - -, •,", all non oint source re u_lattons ; -
P ._..,. ... g L
f e it'have mad the hazardous materiels sequarma nm under Chapter 6.95bbthe . . _
Coliform.Health&Sarety Cda.Sections 8505:25533 ad 25536M understand that
if the building does not currently have a tenant,that it is my respon hbllify to notify the ,
cateuipart of the mquirmonts whibli must he'rinct poor to issuance of a Certificate of
Dec.
parley r .. I,. r. ...
Signature of Applicant Date
r 'r owne,orndho n.d.gcat Dote All roof coverings to be Class"B" or,better
a 1_ ,OFFICE. .. _ .. ... .. . . -
a . err +. .. .. .. - __. ' . .,=.,,-•....... . . • ., 'r 1,