01030123 (2) CITY Ne,o xOND
BUILDINGviNPERMIT CONTRACTOR INFORMATION:
yUILDINO ADDRESS. F17RMIT NO.
101.79 N BLANEY AV CONDITIONED AIR 010301.23
OWNER'S NAME: APPLICATION SUB DACL
WIELEN GEORGE L AND DAWN S 164 B GILMAN AVE: 03/22/200
TONE: SANI'LARY NO. CONTROL NO.
qmv (408) 37
�QZO AItCHI'I'EC171iNGINEIIId'. BUILDING PERMIT INFO
U F., BLDG El
.0 PLUMB MUCH
QZL_I I'-) I I L_I
66�Z LICENSED CONTRACTOR'S DECLARATION Job Description
oz— In nymnnrian f"roed I 1 ,afCartaI)(ur arerg P
� d..�� x5hS 900)orD fifineBa II-fseiol,Cadcad ny harle
Is re LIE Late anal cff�Lt,
O ¢ Date Clara Lrc.N
e. 5TON AC ADD ON CONDENSATE DRAIN.
Dnlc Conlcmlor
'awe w Al2ChrH he use a,labl i I ION
acloo
f ander'mrd my Plan.,troll he used a,naenha rae..rd'
a p p Liccna:d pot
o OWNER-fl Lao,d free,
e,he RATION
betray uldnn dew I am csctnpt from me Cunu'ncmrs Licouc Law B,r the
,2Z_,2 Q toll y eS f ID31 S y I f C A y ly . ,
C o wit paner to orol,r,l, l' p I I':I y:r ee,
isPT II aro 'll I b I:rl ten
mall Lynes r, d 1 , f l ' 1 e 'Io tat) S Ft. Floor Area Valuation
(ro y nepahe ]nWl[the..lei rl nide&, w .nal n,l All,,c C,da) q'
of that too,caa5ert ary ap li and the basis fm the alleged ,c pit(0 Any I torridly C
of Scevwl]f131 S nv any handled
doll la'a permil sth'Im"'h.applicant In a rlvil prnalty
it rte tna,rc rico'live leandred den;er,1851fu. A PN Number Occupancy Type
❑I,ac uw'ne of the pmpvey,army enl,royee,wnh wage',,thou ofe,nmpeusatioa,
—D
Will do the walk,and the'lmclum is not intended or ulfered for sale(See.7044,
00
ya,inea,trod prert,smrc Cede:The Camraen,;,u.en,e ww mire,a..d apply to an Required Inspections
or tit
r of property Who hedd,or IoTEo es director,wed Who doe„udr Work him..11
� mrongh la,Liw earpley '.providing deal took iarpro, ell,r not imendar w 204 — UNDERFLOOR FRAME
Beren for aaic.Ir,lmweveq he nlmamg Lir iinpa,v.r..ctn 1.,old w thin.,rte year of
lm,tnpredon,the LosI—haidder will have Pre harder afpawing mat he did not halm or 301 — ROUGH PLUMBING
Prove Rr rnrro,e id-10.)
❑L as owner of the pm...I,am eLclushcly connnc'iog wish l icee,ed cania,lar, 1, 303 — ROUGH MECHANICAL_
L.111hoel rite Popact(see.7144.❑mare's rad prole„ion,Code)'Ihe cewmeer, 304 — ROUGH ELECTRICAL
t"re,law does nm apply le to awacr of properly who hada,it improv'”lhel'o,
rod who taaarel,lot 'rm p;,,t,with a toil ac l..Of licenced For, I ,,the 505 — FINAL ELECTRICAL
Conu'acmr's L"oe Law.
DlamLocr„rrderSee. .B a p C farde,oce,..n 507 — FINAL PLUMBING
Owner. Dale .508 — FINAL MECHANICAL
WORKER'S COM PENSKI ION DIiCI.A RAI ION 51,4 — FINAL_ PUBLIC WORKS
I hereby affirm under perdly of perjury Linc of the lellow ing deckcati..n,:
7 I have and will ea etain a Cerldimre of Consent do self-insure ha Worker',
O... cil,.lion, a, provided for by Section 37do of 'ha Labor Code, for the
pertomrarcc of the wort for which thio permit is w,aed.
Dihoot
red"III t lrtainWerLcrsCorepen,a'ion lmurance,a,regricd by Section
3710 olthe Labor Code,for the prrformunce of the work hr which this per era l
i,wed.Myworker,CompcedilleIn,mall-carterand Polley aaoherare: FO LE
Carrier: poliryNa.:
CERIHICAHON OF Exi MPT1ON FROM WORKERS* DEC ����
COMPENSATION INSURANCE
('Thio colon oral nal he arnrricad it We Oce nil i,fur one hundreA dnllnrx
ft,I1n)Lir less)
I certify that Ia'he perfaceance of the wort,for which thl'Omni'f%Hod,I BUILDING
.shall n I employ any pceoe Ilia,maner.so a,a ecorainlgw'to the Wool”,
Compcn,,doa Lawx of C,1ifomlr.Dee
Applicant
NO ICE TO APPI.ICAN'I 1;alta reeking thin ecnillere of Exempdor,you,hoWd
neer c sabjce to the Workers Crupcnwlioo,a ...II Lie L aborCada yea nim
Q C fmd�I...reply with ouch pro euro,...thlapc vii'hall he deemed m,oked.
a rl l
HCONS,RUC9'ION LENDING AGENCY
a 7 I herchy'Turn mw mere i,a corwrncllrn lending ILLI Im the pertbnnan,e
Ili the wo k fir which this permit n i.esued(Sec.3119],Co,c)
Q Lend.',Name,
z
Leader:c Add,,,,
V 1 cat'ify'hu'I have read this application a of oLecthat the'halo i rkeoraliin
W F eoi ren.l agree to c apply with all city and county ordinance,and Gale Lew,rehrio,
V mhoildingcin,traeion.aadh,,hy aumnrie.reprnentwivn of tats ei'y m Over spur
'lie.ham,-mearaaed property for in,pectl..n pnrpo,c,
a (We)agoceto save,inderee ly rad keep hrmede,s the City of CapellLw Lgaioa
ti VJ liubllltin.pel'oore',costs rad"Plata which'teal in ary way meow against'!ill
ti SOURCE REGULATIONS un'i't of this permil.
APPLICANT REGULATIONS.UNDERSTANDS AND WILT,COMPLY WITH ALL NON-POINT Issued by: Date
Si,natere of Apl,lacaluckrlmeler Dale Re-roofs
HA9a5RDOUS MATERIALS DISCLOSURE
Will meappel'alnl Lir Ohne baildiagia,hant_,t...c..rharal.haaam..a,to 11e1 al 'type of Roof
a,dewed by m,Ceperdno Nardcipal Code,Chapter 9.1^_,and me Hcahh red Safe,
Cock,Ser'in I°553200?
ClYe' 11No All roofs shall be inspected prior to any roofing material being installed.
Will meappd.rol er male mlikal,o,,, all rise egri,aicd Lir a.vi.e'Wld.'' If a roof is installed without first obtainingan inspection, I agree to remove
emitda,haeaaLie L'inwminmu m dedncd by the Bay Area Ar Qrwlity Amrrgcalca' p 2g
fro,”, all new materials for inspection. Applicant understands and will comply with
DYE, IJ No all non-point source regulations.
I hove trod me I IIaII tnater,lik raider Chapter(1 95 of the
Cali1'ot lie Health k Safety C..1,Scelnn,155115,25533 and 25514.1 undersand title
tfine bui ldingdonnut ratio 1,haleaarae,thad it is my orl'oo,ihadidy to ocatylfa
occeprnl intro,mgaLremcnt,which must he mc' Liir m issuance of a Corili ate of
Occupancy.
Signature of Applicant Date,
oWr,erar a'e'ItLi't..d ogee sate All roof coverings to be Class `B" or better
OFFICE