02030082 (2) OF
CI BUILDING DIIVEfISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10395 BRET AVE . BARTON CONSTRUCTION 02030082
OWNER'S NAME: APPLICATION SUB DATE
SAM WILLIAMS 769 COE AVE . 03/18/2002
I PHONE:
SANITARY N0. CONTROL NO.
(408) 298-6334
p ARCHITECT/ENGINEER:
p O BUILDING PERMIT INFO
aU BLDG ELECT PLUMB MECH
s= LICENSED CONTRACTOR'S DECLARATION Job Description
Sz='w (hereby a)fD!s,that la 3licenu.,ia,sd under Provixions of essam,Cocr9nd license ELECT PANEL UPGRADE . P
u,f hs. lion TH101 pf Division 3 of the Business and Profession Code,and m license
P,E= II fotcc"wi�((ect. �(
O ee a Li nee Clan
Date C in, y
ILL ARCHITECTECLAR ION iota
�
r_ I understand my plans shall be used as Public rtcoNs
i uO C Licensed Professional
se
OWNER BUILDER DECLARATION
X
v 1 hereby off rat that I nm exempt from the Contractor's License Law for the
following m n(Section 7031.5.Business and Professions Cane:Any city or county
❑ which rcquirca permit m vinsauct,elder,improve,demolish,or repair astrucstructure, $1100
Tiny structure,
i3prior to ts issuance.alsoq the applicant for such permuo file a signed smtement.
To.,he islicensed pmirsocanta out provisions of The Contractors License Law(Chapter 9 1,>,..., yn / �e.y Valuation
from n 6 ;NS t 7000) f -Division3of the Busutess and Impassion, �.ti { 373y/�3 U L13, T1 a7I liY.:� �.�:'x:
or that he s exempt Therefrom and the ba.s far the alleged exemption Any violation
of section 903 L5 by airy applicvm for a Permit subjects the-,phimme to a civilpenalty
rOfnetammhmfivehundreddollarsS5o0), 104 PN N8T�qk IPhira Occupancy Type
❑I,as owner of the Imix y,or my employees with wages as Meir sole rnmpca,mion, n 4 _
i
%
will-do the'work:'and me structure isnot intended or offered Tor sale(Sec:7641,
Business end Professions Codntm
Code:The Cocmr's License Law docs nota I to on
Owner of property Who builds or improves thereon add who does such work himself 505 - FINAL ECIY��ItCstions
or Through his own employeesprovided that such i......mcars arc not mended or
,yRered for sale IL howeveq the building - "-- "-- — '---- -------- - ------- - —.. - - ------ _ —___._ _ _...._.
r int en of proving
n sold he did one Year of
cepriwe faron.the .ie of,ric.) will have the burden of proving that he did not build or
improve fur Puryose n[saleJ,
❑l, fin
c Pe.7 am usquevelat t Professions iN fee stdc tnctorst -----
nsnve lh plea(SeSec 7t3W Bux rales dd Cod )The Contractor's
a da. t a.pply m an pwn«of p puny M1 build p s , Pity
.s. _yand%ho,countracts for such projats with onvadorts)licae .pursuam..othe
ContLaw.
lam .,_
1 - t
v -
exempt under Sec. ,BKPG Tor this faun � +�tul,
MAY
Own<r -Date "
2 1
WORKERS COMPENSATION DECLARATION 2002
-I hem by Rim udder y pejury one of the fol lowing declarations: BIN/'lCl p�
Y a ..penalty of D�gY
1 have and wi1f aminmin a Ccnificam of Contin 10 self-insure for Worker's
eompensmipn it, pmvidcd for by Scnion 37W or the Labor Codc, for the
- _ perfartnanca of the work far wnich this permit is issuW.„
❑1 have aditl wi11 maintain Worker's Compcnsatidn Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is '
issued.My Worker's Compensation insurance critter and Policy number ate:
4"1 1l!..I'r.f policy'N' c ., t -
CERTIFICATIONOFUEMPTIONMOMWORKERS R_ ,r 5d Y.:-..•I.-i CY f;t sI; s YQ�t tv'' s �Y'I''
r
COMPENSATION INSURANCE'a'4"-:'• Sri
or less.) jun raced nm be cnmplcted it the permit is for one hundred dollars
(S]W)or less.) ... t
rihall not en'yoN iiriih peKorma eof the
ComPe conemploy n��ppeerso Y mydsfr s ass pate lc t t Ore W k Workers'
uon l.al44f6aYf Oeff3 Z�/�/.1i_y o`evd -
99 11'' ..._ _..
IC tMPPLIGCNf If AradSQs/gN of mot Bx pfo uhould _ -- -
buome bled t the Wok Com t p ns of the Labo Cod Y y must
z Q
forthwith comply with such Provisions or this Permit shall be deemed revoked.
1 "CONSTRUCTIONLENDINGAGENCY
a > - 1 h achy II'rrn th n Th m t d lend ng agency f the pert nuance
— of0m workf«whch thillimmit :' sued'(Sur 3097 Civ Cl"
i
a:� Lenderalbirie
Lend AEd s
it
I nee to t 1 M1p. d al city
and
on and endrinabar nces a above information is
to Imilt.1 agree to comply with all Gity ane ceepame tative cane state laws relating
�.V tobuildingcpnvouaion:and neon Inspection purposes. Ives of this tidy roamer upon
yr'W Nin above-mentioned property far Inspection on purposes.
F i L (W) g os,co de fy and kap h may the City f Cupeni o age nu
Z liabilities,are c cot d xpe s which may y way ace against said
V Z Cit i conuqu c of The gni got Nis •. /'�
A IC NDE 10, AND OMPLY WITH ALC'N NPO 1 I
C no 1 � ' Issued by: Dat v
SigicSt eof AppoPITIC t trot - -'• to /
Y',PPIGA DOUS MATBRtALS DISCLOSURP set Re-roofs
a'" wnTh "amtrm bi ld'nga up tki«e«,liiudl namiaatsurromardid _...Type of.Roof__... ..
d
I
az def ed b N C pcnino M c pal Code Ch pt 912 d dhc H Wad Safety
-' -
CoEe:S❑ecYihii t5^a t. M14 ! 'i s. •w. --
cmthz do en mniam nates tdcfnetl the Ba Arca Air Qublii Mina whit 5
All roofs shall be inspected_pnor[o any roofing matenal being installed..,_ __
wuthe Iat rat ba la `
PP gocap t W pate t e G wmen If a roof Is installed;wi[hout first obtaining an inspection;I'agree''.to}emove
D Get by Y Y B t
❑y �" all new materials for inspection. Applicant understands and will comply with
all non-point sourcereglations' '- - -
I h e d the'fiaza dour m t i I. ymrcmrnts undo tCh Pte fi 95 cf the
Califd nHerlN&Sefny Code.Sections 25505;25533 and 2553a luidemand Nat
if Ne,, g pea not GumnOy havan tenamahal it ix my rc.Wonsibility to natif_v eOeOF
Duca P y quirements w must o issuance of is Cenific bf _ - - -—- - - - - -
d m d
m or Nc
Signature of Applicant S._.
Date
cr :"°^=eaaF te, a All roof coverings to be Class "B" or ter
OFFICE - .._. _..... -- -