02090070 (2) OF
CI BUILDING DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: APPLICATION SUB DATE ,
JEFFREY JOHNSON & DOL RES 09/11/2002
(� PHONE: SANITARY NO. CONTROL NO.
t] O ARCHITECTENGINEER: a BUILDING PERMIT INFO
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.2 BLDG ELECT PLUMB MECH
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= LICENSED CONTRACTOR'S DECLARATION Job Description
z_C 1 hereby Boren this 1 am licensed under provisions of Chapter 9lcomoraving
rn t- wish Section 7000)efDim,iea3of the Business and Profession,Code,and my license
2xf� iamfall form ad effect. TEMP POWER
re c U Liecnsc ClassLic.a
Date Comracmr
Iet_ r ARCHITECT'S DECLARATION
to I understand my plans shall W used as public rtcoods
3 i p O Licensed Professional
OWNER-BUILDER DECLARATION
tan��-'w I hereby affirm that 1 am evempl from the Commctm's License law for the
?Cfollowing reason.(Section 7031.5.Business and Professions Codc:Any cis,memory
which requires a permit to construct,alter,improve,demolish,or repair any structure C 2 5
ria-,ca p' toksmrttt.alsorequimthc applicant fur smh permino flea sigrtM summent ____ _ $
n'3- f ncing i(pdnuembtMe .fDsii,i.ftM1elhnRuaors License L.w,i.napmr9 _-
cooinmcncis 1hSccrgn80W ofDivisionortheaBmidraandii.AnyviCao) " rf"1tV S FL, Valuation
that he rs 9i
or tM1ni lie is eielnpt thcrtfiom and she basis for the alleged ucmptiov.Any violation 't\ "32
'3 2 O 120`62-.'�(]"ti �-')'t 1)}"S
-of Section than v anyapplicant Pora500). subja¢she applicantmacivil penalty'
infant more than five naaarea dollars asw). APN Number Occupancy Type
❑Lasnwnnrnnnepmpenr.urmrempmyeeawitnwvse,astneir,nlecnmpee,aslem 103 - UFER
will do the work:and the suacmre is not intended or offered for sale(Sri.7000 -
Busincss and Professions Cale:The Conimnnr s License Law does not apply to an a Ulre resp ctions'""
0
caner of pm,m,Who Wilds m improves thrown,and who does such work himself
ar er through h m ever.t provided Nm suchimprovement.,kt ended or
oRc df '. 1 If.Ftwever the building - __. ..._.-. .. .._........ ..... _..... ._-. -....... _. _ _. _._... _._..___...
ger mph of Prov s W.,thin et year of
compos,fiv the uwneo.11der will have the W Men of proving that he did net Wild or '
improve for purpose of sale.). '
O 1 - f thepmpcnY exclusively contracting with licensed tractors to � - - _ - —-
construct theproject(S 70W Business nd Profe.s o s Cad )The Cont ter s ;;1't r J., t. II'
Lice L d of apply 11) ne ofp pony h Wild. r improve,thereon FORMAL I �
and who `_cath tact res)licensed ant to.the _�O_ "�'^te!?�
Cyntroctor Lt p 1, \ P
�r
contracts or s c is
Mo. t ndcrS B&PCTs this reason
,. o,r9, �� �t_t o_ OCT 04"2002
WORKER'SCOM ON DECLARATION
IM1erehy affirm under cenahy of pcjuiy otic or Ne following dmlamtionr. BUILDING
?(� O 1 have and will maintani Cenificdte of Consent to sel6insmc for Worker's LLiitl7N�,l
Compensation, as provided for by Section 3700 of the Labor Code, for the
perfmmance.f the work for which this permit is issued.. ,
111 h d will maintain W ker's Coinpe s t o 1 'ounce a.mg6imd by Section
3700 f he Labor Code for the peAoimance of the work%f M1 ch this permit is
issued.My Worker's Compensation Insurance tamer and Policy n mbc ere: ,"
Cam Is d. f:'"t '.' t 1'erPoliyN. .~: 1 't
P: :f tCE nFICATIONOFuEMPTIONFROMwORKERS;.. s i eY } :bt I- 1 S, fp, 1 r St_,. '•:i, n. .I.
deed CO�ENSv nedNf the pc Aunfao hltdredd _
r` (Thstilt ollars ..r t tilt Jill' o. , \ ( tlr .U(:,r'1. "Is
51 W1 I )
- Co - ,. ...-....., ,.
I _
., I nfy iht in the r. I of the kf hich th pc 'i issuedI """"^`•«.-.,-
ly h W rkers
stall t , ploy anY,ce y ne t be< e V
19pc t La�wS of C l f m m
ICE TO-Zi�L ANT If ft rk gn this rtf to of E pun You broad
bcco abjecit theWorker's Compensation p ions of the LaW Code.You ua s 1'
Q 0 faith nhcomply with so on P rovisionso r th perm t shall W deemed resolved,
''CONSTRUCTION LENDING AGENCY -. '" " � I' 1 ;n. T I '1 '„rll -----�
Ib by ffrin th nh viva n I d ng igen y f the pert oma toe
p: .1. . -t.t ,r •. t
t. of th<work for which this pc is issued(S' 309] Civ.C)_
G..Q Lender's Nm
ae ' , r . _ .. _ ._ _.. ...-u. ......_ - ..__._.-_..._^_-_. .............
U-z 0 1.6d!r',s,Addnry
I cortify tM1 t l have nouddri,applicationd thate,hu the hove information is
kT+ E.t comet( 1 gme to comply with all rity'rand county,orodinturaces and state laws rdaung
�.0 to budding conatmcton and hereby autnorze mpmsentatves of this city to enter upon jjj
;a...,(a] the ata e t o d propend far inspection p ryoses.
[-r 4
U g tos demmand k phamnlestheCty fCpen egainrt
iZI liabilities.judgts,costs d expanses h h y y y ga rest saidZ
Ctry ' c sequ 'ce of theg..,,a,of this pe h.
PP CANT UNDERSTANDS AND WILL COMPLYWTf T Oh POINT
cUL ons - Issued by; Date
tAllAI Vnr �I-f1-02
Signal=o pplrtar omractor •• Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
call the applicant o future b ild ng pant storeor handle hi” neo el Type of.Roof _ -
tlef e0 by the Cucen M cJJpal Cod Chalts,9 12and theHealth end Safety
-
Code S t 255J (1 \1 X11 L' \, 4 •_ iii s 1
.. OY t \ IJJN ITI YP he h - t t '.) ' �) 1C, ,
_All.roofs shall be inspectedprior,to.any-roofing material being installed.._
.11 Will she applicant to.Wilding he int useBayAiica p uidayMan9 wmcn If a roof is installed'without first obtaining an inspection,'I'a agree' remove
all non- oint source re ulations. B
ten h raMo rote ¢a d f ed by th B y A g Q 1 ty M gement
°ia`r° all new materials for inspection. Applicant understands and will cote 1 with
❑Yes - No j - PY. -.
r1 1 .. B .t.:'e .
!in ave rend the h znrdous materials reqs remcros'und r Chapter 6.95 of the p r 'ti FIs
Celifoma Health&Safety Code.Sections 25505.35533 and 25530:I understand that
if the Wildingdd snm cumcnd have.amount, it is
. Y my responsibility anaifY the
&cups t f @e iequi¢mems which insist be met p - to issue a of a Cenifcete of.
°°0a P ry, or
Signature of App
licantDale
I :n ..use . - ... ._. .. ... . .-_ ..-- _.. ...
atnor aced agent n
All roof coverings to be Class,`B or;better `
...' ., 1. .Y d ! ......