01070101 (2) CITY GUDIVISiO PERMIT
Nc CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21432 ELM CT WATER HEATERS ONLY 01070101
R AWY" DOHERTY APPLI TON 2 DATE
500 AIRPORT BLV 0723/2001
PHONE:
(415) 349-3747 SANITARY NO. CONTROL NO.
O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
U BLDG ELECT PLUMB MECH
< LJ L.7 IJ I_I
5 i m LICENSED CONTRACT'OR'S DECLARATION JOb Description
Z
z_a 1 hereby affirm mat I am licensed under provisions of Chapter (commencing REPLACE WATER HEATER.
F:t- wim Section 7000)of Division 3 afore Business and Profesions Curb, ad my license
cem ; is in full force and effect.
�o�`u Lieen.e Cla.a Lm.a (50 G GAS WATER HEATER) .
ad 3 a t- Date Contractor
"• ARCHITECT'S DECLARATION
a'J,Maj 1 understand my Plans shall be used as public records
�r
yO O Lensed Professmnal
OWNER-BUILDER DECLARATION
ad at
1 hereby strum that I am exempt from the Contra Co License Law for the
my
< fallowinguirsna permit
]onstr Businessand Professions Code Any city or county
O which requires n permit requires
e airs the alter,improve.demolish,or repair any structure
i 3
prior ts' a al q i sth<applicantfo hpermit oflsignedawtemem,
thallin rs l c of d Inament To he pro :,was iNthe C uvcmrs License La (Chapter 9 S Ft Floor ACea .
(c enc it with SG to,70M)of Division i fm BusinessdadP fessonsCd) S.il y F .0 Il'f S ,/r .1 ('I "y,. ValUatlOn
ar that he is exempt therefrom and the basis for the alleged a ption.Any viola mn
-of Section 7031.5 by airy applicant fora permit subjects the applicant to a civil penalty
of not prone man five hundred dollars(s500). APN Number 'IF '*!'' I Occupancy Type
°1.as owner oRheProperty,or my employees with wages as their salecompensation. 502 — FINAL PLUMBIN ENERGY
will do The work,and the svucmre isnot intended or offered for sale(Sec:704L- 5 0 6 - GAS TES
Business and Professions Code:The Commcror's License Law does not apply man TRequired Inspections: -
Owner ofproperty Whbuilds p fl n,and who does such workhmself _ 507 — FINAL PLUMBING
or Through,h- wnemployees provided that h improvements rc tintended or F
-;ofromils If,h a the ti Ido ....___ . . . _ __. _._ ... .-_.-.. _ _ .._._ .. _. .._.... _
g pros li ,,within ane year of - — —
oprove fa The
owner ,builJer w II have the burden of prov ng mat he did not build or
improve
for purpose of sale.).
f]Laenwner 0f,(be
Papi-am-Bexclusively contracting with
licensed Cont n t
construct the project(Sec.Trial,Business and f. ons il The C nt t
License Law does not apply
to owner of property who bisIds or imp t
LE
ii .antl h tinct f such p jec¢w th commissions)I n ed.p odor '. t -;. :;'l �•
t the
Cont t I L<e La
°1 a.Tied,p,under Ser, &PGfar,thiareaaan ;.0 7 2001
Own to
WORKERS COMPENSATION DECLARATION BU'LD1JYG
i.., 1 hereby affim under p naltY of P ,sa f 1M1.follow n8 dicamat ons:
❑ I Love end will ma uta n is Cemfcate of Consent in self-metre for Worker's
Compensation,:as provided for by Section 3]0(1 of the Labor Cope, for the
- - performance of the work far which thil peirmit is issued. .
Cl 1 have and'will maintrialWorker's Crmpe t Insurance, required by Section
3700 of the Labor Cod•for the relfirommake of The ork for which this permit'is
iss d My Worker's Compensation Insmampecarrier and Po l cy dumber arc.,
Camr
Policy N
tt i CERTIFICATION OF EXEMPTION FROM.WORKERS u
'-,COMPENSATION.INSURANCE 1 -1.11t -
.. ...._ ._ _._. ...... _
(Th' enlo 'need nm be c°'mpl<ted Rhe permit is fur one hundred dollars '-1' t,lr t „•I t� :,)[ �
ran er as ro
n to prat in the pe f of the k f ht h th - "-
shall temploy any,P< in become mboop to the Workers'
Compo at Low,of Cut f e Dole'
NOTICE TOAPPLICIC ANT If after nuking m's Certtficntexempt of E -pn.on.You should
zbermad laribilat the vAlk"'s Crimpimsalk,im previsimiIth Labor Code,you..it - - -
0 O
forthis ith comply stiff ch provisions or this permit shall be deemed revoked.
I, 'CONSTRUCT a ION'LENDING AGENCY - . .
a.' I KIhiaffirm tarnconstructionI 7,C sge Y f. to perfonri ce .
W .y 'L o Na which m admill, "'ed(S c 309) CIv.C)
d. ' Led r.Name' _..-, ...-...
Z Led Add;ads,
rc'y hat I hmad this application d state th tth b information is
E.r rte t 1 to comply with 11 rily and county achaturess ad t t lacing
-rJ -tobldng construction.and hereby amhom representatives of this city to enter upon
'Thlaw,a-mapammodfiroppery - spedp
(we)agree tos e ddn ify and k Fm lieCty fC p noaga
mt
t5O liabilities. pcov adexpo swhich yin any y a againstsaid
Ctnco veruBF the granting of this permit I '
APPLICANT
UNDERSTANDS AND WILL COM FL4'MRH ALL NON-POINT"
SOURCE RE00LATIONS Issued by: Date
Sign w<I Appl,,maa_ t ctr -; . .." Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W1 theapplicant or fatilrebuilding«c pa t store orhandleh doesmaterial Type of Roof.
s derned by th Cupm1 M n<p 1 C d Ch pie 9 12 d th He Ith o d 5 f ty„
Code S tf n 25532pd ; ';; e
°Ye °N° All roofs shalLbe inspected prior.to any,roofing material being installed___
Will the dr,plicam ar t t rt building«c.,am use extudlimer, device,which�. If a roof is installed without first obtaining an inspection';`I 3gree'to,remove
tbacdl a ocnt mm darned by the ayAieaA Quality g
District all new materials for inspection.,Applicant understands and will comply with
:1 : st CN. ''1 all non-point source regulanons.:,.,
1 h read the h Nus atenal rey varmair under Chapter 695 sof the
Cehfomia Hedltb&Sof ty CMe,Sections 25505 25533 and 25534 1 understand tha0
if.ittbiddingdces notcneilly have ate nicht it is T,
at m n6ufy the
pa tall
c -f th' gnirem t h¢ti must M m t primp,iss a of,a Cenifcme°f
ccup ,
Oy. j.. -
- Signature
. . ... _. . . . -._ .._....._- -. ._..- Dae
Date
All roof coverings to be Class B"or ow o aamortzw,ag nt - better .
r!r'. ,1 _ •/- -; - - .OFFICE
tis:; e . ., - •,