00100228CITY
I DFDISONc
ViN
CONTRACTOR INFORMATION:
BUILDING PERMIT
BUILIJING A DDREiS:
PIiRMI'I NO.
.•O
OWNER'S NAME.
APPLICATION SUB DATE
ONE: —
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SANITARY NO.- CONfROLNO.
: ARCHITECIAINGINEER:
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BUILDING PERMIT INFO
BLDG ELELTPLUMB MECH
1�1 I_I 1-1 1.I
LICENSED CONTRACTOR'S DECI.ARATION
Job Description
I hemhy affirm ,ha, l under p g
Poore(mm,
3.] ,he 111
andlice,,
tall inn]INMq ofectMakin. J ofthclnwiness and Proles.iannCWa. anJ lay liceme
I, in
•
,,lull lar nd.ffed.
Lire Class Lies p
Dae Contractor
ARCHITECT'S DECLARATION
REPLACE 50 GALLON GAS WATER HEATER
j I understand my plao, hdi cuoral as public rcmrd,
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Llcnu.ed Pmte,ional
OWNER -Bi DECLARATION
I hereby affirm ohm 1 am exempt rum the Contractors License Law for the
lollowin, mann, (Suction 7031.5, (roma is and protestors Code: Any city or cnomy
i which rcgdms o pClmil a, mm"umn, alcor, Itnpowe, donmlix11, or,<palnmy ,vuctum
prior to its issuance, rho requires the applicant lit such Irani) to lite a signed.omnnenl
Sq. Ft. Floor Area
Valuation -
that he is lircnad paramour to the previsions or the Camraetoes Limns Law ochalser 9
(commencing With Section 7000) of Division 3 of Business and Professions Cods)
or that he is exempt ,hcrcrroa and the basis fanhu lix,rd r,aamio I. Any violation
of Sccdnn 7031.5 by anyIq, lheara Bra a panni, nubjecw tit c,"' icum la a civil ,anally
A PN Number -
Occupaney TVe
mf no, lame than rive h,mdmd doHan l$5(XI)
b 52
❑ I, as owner of the pmpa"t or my employed with wages as their sole compensation.
Inspections
will do the work, and the ,,tractors, ix not imerdnl nr armed Ill .sale sec. 710o,
Inkiness and Pmre,Qon, Cn le: The C:,I,baetm:e ueanxe Law d,ea an, a,yy a, a.
hpired
r of pmperty Who builds or improves thereon. and Who dreg such work himself
3620-7020. k
,,, through his own emPlnyms. pmvided,ha, such im,woanenn are net intended or
offered for at.. If, hoarser, the building or impnwemcm is sold within one year of
ImIrple0an, the ownerrbulldrr will trove the harden orpro marina hr dict nor head or
502 - FINAL PLUMBING ENERGY
pmvc fur purpn x of sale.).
`
506 — GAS TEST
❑I.as nwanot the pro,en, am excltwi.dy trammeling with licensed contractors in
cjinstruct the project (see. raw. Buoinc , and Profession. Coria) The Contractor.
507 — FI L PLUMBING
.s e Lawd ac nm app, to m owner of propra, who build, n, impm ¢,,bran.
Ind ,deb pfnjCCt, Wllb a tnnlNelnf(,) I.Cllved pml,nal,l In IIt¢
mo ILicenseL
Common, am ex s pt License law.
❑ 1 am oxen),, under 5¢. . D & P C for this maw
Owner r Dam
WORKER'S COMPENSATION DECLARATION
LLL
I he city nRrou under penalty of perjury one of the following declarniom:
J I hoc ural will n Humin ti Cmurleme of Conan, u, ,e114,ur, Iib Worker's
Cnmpensmian, as provided for by Swion 3700 M' the Itch, Gale, lit ,he
performance of the work for which this permit i, issued.
01 have and will inumain Worker, Cont,ansaion Insurance, us required by Section
9700 of the Labor Cmlc, for the Ierlrtmtu¢c or the Wad lit which his prom, ix
issued. My Worker, Compensation Ia,uranm carrier and Policy number are,
Coram, Policy No.:
CIiRTIPICAI'[ON OF EXI MPHON FROM WORK17RS'
COMIIE.N SAHON INSURANCH
(This .anion need nm the cmnpined if,he panni, is for one hundred dollar
MIKE sur bass.)
1 eerlily )hall In Ilse purl in'n,mea of the work for which Illi, rerun is iswed, 1
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become wbow, ,, ,he Wneci
,hall net andoy any per any an no n r ax in d.
Cmnmaina LW, of Califi,mia. Data
µ
Applicant
A ,Cr 'F,) APPLICANT: It, after making'his Cedifin,c of Exemption, you ,hoard
rectum,.bj¢n to the Workc,, Cnlnpvrval proom o s or dm Labor Cada you must
Ii,nhwim n,tuply with such puvi,intu or thi, porion .Quill the dremed invoked.
CONS I'RUCfION LENDING AGENCY
1 machy affirnuhal them is a commotion lending agency for the prformunce
oI the work for which Ihis sconil is issued (Seo )IAP, Civ. C.)
'
jLender's Natne
Lender's Address
I cattily that l have read bo appllcalion and ,tale that the above information is
r.en. 1 agree In cmnply all all Puy and atunly o,daanaesand ,are low, rclming
,
m hddingcoa„renin i, and hereby mribmae aporseco se, of used' to noel upon
the abne.mcarioned prolsil for insleaion Im"ws.
W,) agree m neve, indicato , and keep moradrs, the Ci,y of Cu,erino abmro,
7 liabilitiesjmdgtnems, costs and ex,a na, which play to tiny way acema against said
: City in nmseyucncr or l he granting til this resit.
,
APPLICANT UNDERSTANDS AND WILLCOMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Signature sur nppLemNContranar .Gum
HAZARDOUS MATERIALS DISCLOSURH
Will the applicant or future holding aeration store or handle hmnNnus material
Type of Roof
ass defined by the Cmpcnlno Municipal Ude, Chapter 9.12, and the Health and Safety
Gide, Section m 255321.1' No
All roofs shall be inspected prior to any roofing material being installed.
will he ap,l ort or furore buildingoerupml use equipment or dr,we, which
If a roof is installed without first obtaining an inspection, I agree to remove
it hat'air contaminants a, defined by the Bay Arca Air Gual ray Management
all new materials for tion. Applicant understands and will comply with
is ria^
El Yen 0 N
int
all non -point source regulations.
I base read ,he It ... Won ...... our, mgmorowal, under Chapter 6.95 of the
Califoram I le rlth & Safny Cock, Semon. 25505. 25533 and 25534. I understand that
if the huildba, does not cmm,m y M1ma u term, ,hal it o my re,,oa,ibiIa, ret notify he
nrnaa, or d:a rnprn eNcmx,1111¢11 mall he real ,rim I,, i, narec of a C'enie.me,,I
,
Occupancy,
Signature of Applicant Date
All roof coverings to be Class "B” or better
I
Owner or andamired agent Darr
OFFICE