01120053 CIrun DING o ESION PERMIT CONTRACTOR INFORMATION:
BUU.gIYGA "MRKSHIRE CT PERMIT NO. 01120053
OTR��t)Pl!tTTI EUGENE J AND ELLEN M APGL7(AJTA.S fYfl1
PHONE: SA.NLITTA/RYNOO.. L CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
O C BLDG ELECT PLUMB MECH
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LICENSED I n CONTRACTOR'S DECLARATION SC(IpIlO❑
1hemgaffirmthat1amlicensed 0theBunderpnddionsofCharlie,Code9(commencing FIRE PLACE REP LR
m r m with setinn c anp al Division 10l Inc Ruaincss and Pro(c»ism Code mi
is in full force nnJ flea
O w< ' Data Cl ss - Lica_5��/
Data _� eommnor_A.I(_pn�.
t u y ANCHITECT'S D[CLARA,'1�50ttYY
C
ua erosion my plans shall be usce ax public records
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Larged Professional
o i OWNER-BUILDER DECLARATION
1 herebynaso affirm thio I ion prom from the Contractors e:Any,Low for the $1000
a following n,uoo.parfait
section 7031.5. t.amus and Profusions Code:Any airy or weary
o,F do whim requires n period..ac ronxwn,altar,improve,demolish.i fi repair any structure
a. indo .,he s icargad alum requires theap......Distort mcM1pemrinnfilea,Law,Chapter
- - - - - - -
-
(commscen with Section
he fof Division
3 of the urines ucwsc Law,wong Code)
,36q'Fil�'WBr.Pft4h�- i Valuation
(commencing exempt
Senion TL%1)of Division3of the Businessand Professions Code? i _. •,
or that be iv exempt Therefrom and the basis for the alleged exemption.Any violation
of Section by any applicant for aPermit subjects the appliwmtovcivil Penalty
of not soarer.Than than rise lirnarea anu:mra asap. 51 CPN NtlM&L BUILDING r Occupancy Type
❑1,as owner ofthe progeny,or my employes with wages as their gale compensation.
"will do the work;and the structure is not intended or offered for sale(Scc.IIW4,
Business ad Prnms.innx Crae:The Cones aamrs License Law does not apply to an Required Inspections -
orae
r of property Who builds or improves thereon,and who does such work himself
or through his own employees. budded that such improvements mems an not intone
of _
- offeredfor Sala If,however.the building�-oTim improvement within one - �f - '- � - -- --- -- ----���� ----- --' --- - ' - - - -
s prn.eme year o :. . .
improarplanot,the owner-builder will have the hoiden of proving Iha,he did not buIIJ or
I.
over fur purpnae of saleJ.
-O j.as owner of the property,7 am exclusively a contracting with licensed contractors m'
construct the project Tapp.Ito air
Business arta Professions Carter)The ,as Thereon,
.
aLicense h Law Boas nm apply mrd owner of property who bunds s improve thereon,
.. and who r',Licens for-such prnj[CIx.N'llh a CnntfaClOr(S)IICCnSed pursuant to Ib[ ---
01 am exempt
uawde law.
❑lam exempt under See. B gsPC for this reason - •''fi
Owed,Own Data
' WORKER'S COMPENSATION DECLARATION
>} I hereby affirm under penalty of perjury one of the following declarations
` ❑ 1 have vad will maintain a Cenifcme-of Cmoam self-insure for WorAds
Compensation, as provided fr oby Section 3700 of the Labor Code, for the
performance of Ibe work for which his permit Is issued.
❑1 have and will maintain workir's Compensation Insurance,as required by Section
37W o1 the Labor Code for the performance of the work for which his permit ix
issued M )&W Cimitinnor alitP InoreNcranial Padd olar runaround
�' _ .... .. .
m CERTIFICATION OFSAT N I FROM WORKERS' t • • '
COMI'ENSATIUN NSS URANCE " " ' -
(Ths senion need not be completed if the Permit is for one hundred dollar
Ia Io0l nr less.) ,
1 carry Thal in the performance 11 the work for whmh this permit's Issued,I
shall not employ any pcoon in any ma as m become subject to the Worked' '-
Compensation Laws of Colifnmia.Data nc,
Applicant ._ _ ... ._ . .. - .. ... _ .. .. ..
NOTICE TO APPLICANT:II.a(ennaking this Cenifcme of Exemption,you should
become sobjectto Ibe WorAds Compensmidn previsions of the labor,Code,you most
Q Q forthwith comply with such provisions or this permit shall be deemed mocked.
CONSTRUCTIONS LENDING AGENCY
} 1 hereby of ran that than,iia construction lending agency for the pedonnaltae
,.., of the work for which this permit is issued(Sec.3W7,Civ.CJ
0 Lender's Name -
a Z LoTdm's Address
U 0 1 codify that 1 have read this application and side thin the slave information is
'W� E. 'eom:et.I agree to comply with all city and county ordinance and state laws relating
CJ tto he andregconmructiogpertyfhereby authnonpurposcmativcs of this city menicr upon
} gs] the above-mentioned preen,for inspection ad keeps
purpaus.
ti y
(we)[5gme t,"'a indemnify ad in
he way of sector,
egainn
Vi liabilities,judgments,core dna exPcn.as perm may in any way accrue against said
C.1 IZ City in comequcnco of the gran' f thi.a perms. tr -f
^I tAPPLICANT UNI3ERSTANI A )F�ILLC6yL�LY'e'ITH ALL NON-POINT Issued ! Date
Y:
Sigoamrc of licdn(7 n rector —� Daub Re-roofs
HAL RDOUS MATERIALS DISCLOSURE
Will the applicant re future building oi'mpvm gran,or handle haandous material Type of Roofas defined by the Criterion Municipal Code.Chapter 9,12.and the Health and Safety
'Code,'S
..Yes 25532(al:' :,- �No, a l
': 1;' .
All roofs shall be inspected.prior to.any.roofing.material bei ng,installed.
Will he applicant ohadinebralifiragoic.,ral me'impaction or rtes as which if a roof is installed'without first obtaining an inspectioh,.1'agree to remove
•
District?
u a n gat T.as Jef lea b)the Nay Area Air QYII ty Management District? all new materials for inspection. Applicant understands and will comply with
-� t7ya
t. •�!au _ all non-point source regulations.-
-I
egulations:-I have mud Thi IT...or...materluls n, rnncros under Chapter 6.95 of the
California Health&Safety Coae.Se s255p5.25533 end 8514.1 understand that _ _ -
ifthebuildingdoesnotcdent[, ea rt at.That it' my responnibdoybo notify the
occupant of me oce, mens w¢h n he mel P r to issuance of a Certificate of
Occuprncy.. .
Signature of Applicant Date
o.nenram aero - o All roof coverings to be Class "B•' or better
OFFICE. . . . . . . .