01060013 (2) INO
CIsuaucDSOIVIIIN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
AM APPLICATION SUB DATE
' CONTROL NO.
'ARCHmECOENGINEER: BUILDING PERMR INFO
SLOG ELECT PLUMB MECH
ZZ ' r"-i 7-1 r 1 C__I
Z N Z LICENSED CONrRACfOR'S DECLARATION '
Job Description
0 Z h G I harebry.fifirm sten+1 em licensed under provisions of ns Chapter Cad..r(commencing p
l;,tet Lim Settion'IC001 of Division lof m<Businesa end Professions Cod end my license
y6 Lim fun forte ane cl 7
p� Licetue Clus Lic.gT I
3a� Dat= (-k-vs Contractor rv/ H y REPLACE TUB & SINK.
°5 1 understand my plemC,hollE0,used z.public mctmis PUT NEW TILE AROUND TUB
zoo L¢cnsad Professional & REPLACE WINDOW.
0! OWNER-BUILDER DECLARATION
to I hereby affor that 1 am exempt from to.Contractor's License Law for da
F?< following..on,(Section 70313,Business and Professions Code:Any may or county
F€❑ which requires a Permit re conswe,altar,improve,h demolish,file
repair any xwcmrat
prio to tai trance, I req me applicant for Such pemut to fiteaSigned stata t
(commencing
cm n ensN pursuanudme ofDivisi of me Convacmh Littnu law(Coapt 9
(c mmcpcingwith Section TWO)of Dtvrsionlof she Busituu arm Professions Cad) syr-,t)?,.l r.Cq,,f.,FIOp;AreaFk�l.lTo }-� , � Valuation
or th n he is exempt tliertfrom and the basis fur see alleged exemption.Any violation !' 1 ,
of Section 703 13 by any applicant for a permit subjects the applicant to a civil penalty '
ofao'more man live hundred dollars(S5W). APN Number . . Occu ancy Type
O 1,d owner of the and
the structure,ru my emplo t in with wo,ex a ed f sole c.m cc:7(v n,
$400
wnl du'the work and the atis not Intended-or-o Law for-sale o,apply
to an
'owner of property Whom Code:The Comfacmr i License o d does not apply to an Required Inspections
owner 36925038 . 00 +
or through his own employees. buildM)hm such improvements arc not intended or
compile for sale.IL however the building a igen oemcm n sold he did ane ill of - ----' '--'' -_."- "--"-''_ '.--'-"'-'-"'' - - ----- --------
improvefa,me ooe.fluilder will have the burden of ,wire Wtensed con°iracrorsa101 FOUNDATION
nn ((�� -<,''.
improve for puryou of tale) proving
'conswct me un Boso s, consracno - E P 1 2x'0 01'
protan(S c ]Oaa,Bax; a and Profaxions Code:,Thc Commctor's 10 3 - UFER
L c U dues not apply to an owner of propcnY who C Ida o prow thereon,
.. ..and. he cmdamu ro h Prgm¢ th t vman.)I< d p .ant a me _. 10.4 _.-..-REBAR.. -..___.._. .J
G t tis LmeaxeL � IL®IIVG
OI exempt und<rS B:PCfmmis rtason ^^ )C'_•s
105 - ANCHOR BOLTS
Owner Dim
WORKER'S COMPENSATIONDECLARATION 106 - SEWER & WATER
-fn afim.nd, _ - 202 = UNDERFLOOR PLUMBING
ereby penally of peijury one of she fonowing dedamtiorm
o I nd.e'nne'wul maimam a'Ceniecata of Consent ro xdt-mxaro mf waa=r'a 203 UNDERFLOOR MECHANICAL
Compensation;m;providcd for by section woo of�ma Labor Code. for me 204 UNDERFLOOR FRAME
perf of the work for which this permit is issued..
Ihayeamiillmaintain WorkeiCompensatiodihsumnee,as«quiredbySection
205 - UNDERFLOOR INSULATION
700 of meLabor Code,for ma perforator..of Il work for which this permit is
ts 3 O 1 — ROUGH PLUMBING
ird:My W.rkals ompamahon Insurance carrier and Paltry number ere.
- •C. ,--
' cafe F�r:,,'<-;Lr't: ,.. PryN.: At9/0zz3z . �:. t-302: � TUB.. &�;OR-'SHOWER--
CERTIFICATION OF EXEMMON MOM WORAERS'j ' 3.03-`-ROUGH 'MECHANICAL
115th _ COMPENSATION,INSURANCE„. .—___... _. _
30.4 ;ROUGH-'ELECTRICAL--,:- ' —_...-----
rlhis section need nm be completed if the permit is for one hundred dollars 4• +: t'%�'_
305 - FRAME
enify,mm m the performance of the work for which dais permit is issued,1 306
- HOLDOWNSI I W
shall not employ any person in any manner so as to become subject to the workm'
•.r' n
Compensation Laws of Cali Fannie.Date "
Applicant--' _ 307 - INSULATION
.'_ ._._ ._. _..... . . ..
NOTICETO APPLIeANT:IL after Compensation
this Cenificam o(Exemptiode,you you
308 - SHEETROCK
Z become subject the Wolds Colons of mon permit snsbbme Labor CWayou man
cc rannwimmamplywimmmprov;xian nrmixp mitxnanu a«meafevakea. 309 - EXTERIOR LATH
-;� `• ' r°' CONSTRUC71ONLENDINCAGENCY ' 310 - INTERIOR LATH
I hereby affirm that hem N a construction lending agency for mepifmmanc=
W ofth kf hRhm pew'' rss d(S 's09"I'Ci,C) 311 - SCRATCH COAT
}
L -- -.-$ .. —313_-- ROOF NAIL_ . n
4 Q Led s Na
�cZ Lcd Add cis v / ,' -
Vlanifymatlhavertadmisapplicationwdstaudmtma.boveinfomudonis 501 - FINAL ELECTRICAL ENERGY
cartecs.f'agree tm comply with ail city and county ordinances and state laws misting 502 - FINAL PLUMBING ENERGY
to building contraction,and hereby amhorim rcpmsentatibcs of this city to enter upon
W the above-mentioned property for inspection purpose.
A. (We) indemnify h.nmef;I cn-fC.vino ' 503 - FINAL MECHANICAL ENERGY
_ E.. p m ,tens 504 - FINAL BUILDING ENERGY
rA liabilities,judgments,costsand expenses wmmh may in any w y acc a against said
CiiY in conse9ucnee df the gmming mf this Pcwir.
- - APPLICANT UNDERSTANDS AND WILL COMPLY WrrHALLNON.Pl, Dffie
SOURCE REG uLAnons - ISSUCA95 - FINAL ELECTRICAL
f?
c; Sprumrt of,1plmen... «or• � � '• s. Data ,; Re-ro
CH-
Wil '
HAZARDOUSM.ATERIAISDISCLOSURE - 7 - FINAL PLUMBING
fil me apphnnt fume b ildt,Occupant vac oe handl haaereads marc+W _
aid tlme32O1no Municipal Code Chapter 9.12,and he Health and Safety Type„ -Hof.- 'FINAL,MECHANICAL _ _
- +
Code sect omv25sLl 1 . . ."
All roTM
o`fsOs�alCbeFi d ny roofing.material-being installed. .
Will me applicant or fnuml ld ,°clap t se equpmemo d es which If a roa`fJis ii it ll�cT i�f�eSut aan snipearson;I agtee'tor iemove
Di t h mrd s au c num nano a de0n d by the I u Aim A Qdal ty Munegemem`act all,nesAih6terials1?JrN' ec�W_ZAJM%stands and willcomply with
oY "° all non-point source regulations:,,utI have.rtad me hazardos mammals am.iremems under Chooser 6.95 of NeCalifornia Heald&Safety Code,Sections 25505,25533 and 25531.Iunderhand mat
if da,building does nos currently have a tenant:mato is my responsibility to naifytheO/
occupant of me requirements which must he met prior m issuance of a Ccailwse of C
^• r; Occupancy.
_,Signature of Applic Date
_ -" ant
Owner or authonsd agent g Date . All roof coverings to be Class "B" or better . .
OFFICE. . .--