02010103 (2) CIBUILDING DSIONO
IVIiSiNPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
7422 FALLENLEAF LA FORSYTH MYRON G AND LOUE LA M 02010103
OWNER'S NAME: APPLICATION,sUB DATE
FORSYTH MYRON G AND LOUELLA M 01/28/ 2002
• PHONE: SANITARY NO. CONTROL NO.
G p zo ARCHRECrIENGINEER: BUILDING PERMIT INTO
kC BLDG ELECT PLUMB MECH
y<- I f—J I= LJ l_]
I y Z m mm LICENSED CONTRACTOR'S DECLARATION Job Description
OO z_o I hcmby afar1 am licensed under provisions of Chapter 9(commencing
p„t,:, with Section 7”)of Division 3 of me Business and Profession.Cada,and my license REPLACE WATER HEATER.
m ,-u, i.in fall force and cffiam
z 6 License Chris Lid.x
uei
0,
U Dam Contractor
t+ ARCHITECT'S DECLARATION
t=O g 1 understand my plans shall be used as public records
f Jr
iX p p Lmcnsed Pmfesvonal
w,g, OWNER-BUILDERDECLARATION Contractor
ON
1 hereby aR theon 1 am cBusin fromand Pin Comracmr's t:Any
law for ibe
55 a a following massa lir '"n 9om"o Business and Pmfessions Code:Any city or county
,D wM1;ch requires u pewit m conzwct,alcor,improve,demolish,or repair any swnurt $250
of
63.p .Ano to o"In
s ante,also rtquves the o"car m such pemutmfileevgr,W suumem-
that he gt c sed Purs ons so coq provg�pns of the Consracmh L ttnsc Law(Chapter 9 ! v v _ Valuation
ap tg;,ims tien90g07orDrvssn3pnneBp.nd.aaaJPmreulon.cpae) ��Ca(2:
......
r mar he f _1 led
merefrbm and me basis for she a"c cicmpi4d.qny violas an ° i
-."salon'01111,
03 LS by any vpplicam for a permit subjats she apphr m a civil pcnehy
of no,tents".a eve hundred dnnnrt(ssl>nl. 301'4pNI�bTp3I14 PLUMBIN " �`� Occupancy Type
❑1,as owner of she property,or my employees with wages as their sole compensation,
will do the work:and she structure is not.mended Or for sale(Sec.71 4 - -'---- - - - -- - --
Bus d Profess pal code The Conwcmrs License law does nal apply to an 304 ROUGH ELMgWRa MAftctions-• '• -.I
ow
f Property Who builds or improves mamon,and who does such work himself
Arm gghh Own employees.p ideates such improvements of intended or 505 — FINAL ELECTRICAL
f a
oed fir sale If,however the'bu Idle - - - - - ' ----'-'_ --'--- - -- - --
g burden
ofinem la 'thin one year of -_-
she ownerbuJderwJlhavemeburdenofprovmgshashedidnotbuildor 507 — FINAL PLUMBING-
completion, � �-.•. r'q, •ft t. , ,
improve forpmDareofsale,). 508 — FINAL MECHANICAL
.as owner."be ncontracting
am Bovines.,and
ns Coa)The Cmuaorsso _._._:`—
conswn the pmjeds(Sec.]OM.Business and Professions Coda)The Csnwcmr's L " '
License Law does not apply to an owner of property who builds or improves Merton, . .
and ho contracts f h pmjccts.with a uad,mis)licasud.pursuant tofire __-- -
C t s Law.
pr nd .. B&PCf itis son
OW: Or � � ' ZPo� ' 2 �
Ijl ERS 1PENSATION DECLARATION Q
I hereby a1Rrm/u pen Isy-f Pe jury f me following deelarm ons. / O�
❑ 1 have apo will main'arm a Ce'niflete of Consent in
self-insure for Worker's
_
Compensation. as provided for by Section 37M of the Lather Code, for she
performance inform work for which this Permit is issued.
❑1....and will ma rrion.WorY is Compenlaion hisim ace,as required by Sation
3700 of the Labor Code;for the perfowanJe'of Bit,
Or which this permit'is
issued.My W ePs Cion,scoadmi Insurance ciant,and P I ty be are:
s [I Tt id FEXE cy No.
Came i ,• -, S 11 �`r;"'. Pi-•1 Jx. .$1'•�i-.. ` .
'CERTIFlCATION OF EXEMPTION FROMWORKERS - - ,� 1
,_, fOSUR
,____COM INSURANCE -• II
. _ _ .,.,
---------- __.�... ........
...._..
a (Th non need nm Ifo on
completed f she permit is for one hundred dollars100)or lroj
1 can, ,matt the ... . .. -. - - .. .v ..._.._. ........
Y pert hh k f Which m Permit tined 1 ._.._.
Cii. [employ any pe:en a any ma as m mcnme mbjca m she Workers
Compcnsmien laws of California:Dalen manner so
-
wpplicans'- -
NOTILETOAPPLICANP.If,otheWoker'sCtr akinn Cecil cat IE tet ---
b'eco been sheW k- Co 8 P 'You h Id - ----_ - i•: •' :L,
Provisions of the WM Cade,you mull
C
O lonhwnh comply wile uch Ates s ons or mus pewit shall b deemed revoked.
a
'' CONSTRUCTIONLENDINn AGENCY _Ih by R mmm themiscionstruction lending 7.'Civ ' ,agency mperfI .I c
ofm kf ch
wh ch ap 1's sued(S 3097.'Civ
fa dasName
= Z ItcdrP,iAddmsx - - .
V � .1 comfy that 1 have rcud oris v and co and sate mar she above mfmmauon is
.'W F corrtco-1 agree un comply d he all city and county cmti ordinances and sum laws rclming
f�.TJ mbaturve-melding nfioned nand heor Ortcorixmposes, vet of this city memer upon
k7 the slv(We)erne In save. yfor lyindiknpurposes.
(Wc)agmets.cost indemnifyses whihamay to an wayacric a,ddgxiaa
W. cit
liabilities,judgments.costs and expenses which y n any ay gainst said
U'z pit r
Y. TUNDERSh g ming of MILL COMPLY WITH ALL NON-Pbl. 1 /
so
It
?NS.! / HOZ Issued by: Date
adv ommnor '.. , asp Re-roofs
�- - "-�H ZAROO MATERIALS DISCLOSURE e,
Will the ppfcans fm reb 'Id g cI, t toorh dleh Neu [tri 1 Type of Roof_
as❑1 red by,the C pen Municipal Cad Chapter 9.111 and th H Ifoends af t -
Code S tion 25{l (in - y ---
.. O Y s { N yi S�b P'j
- - _ All roofs shall-be inspected prior to_any roofing material being installed. _
• ,
Willis, poised t tet _pu 1d egOccupant :<equipment aWhich If a roof]s Installed without first obtaining an inspection i I agree to;remove
em,h b s ma pts as defined byte Bay ArcaA Q ItyM 'gm s
°i" " all new materials for inspection Applicant understands and will comply with
' - • alCnon-point source regulations , : - ' ' '
1 h read b d . mmeri I requirements una Ch Iter 6.95 of me ' " ee •' �I It)!. -
C6hfOmiaHcaRh&SafayCWe Section 25505.25533and25534lunderstoodmm I
iPmebuddingdoesnor moonily hme o¢nam;ma[it is my msp...inlitymnosify the""' -"'- " .. .-. .._.
um of,hc requ' mei prior so issuance of a Ceriifcam
occ e
•s . .
/Z�_p
Signature of Applicant
Date
_ o p aud,pr;zep g nt D All roof covenngs to be Class"B"or better '
OFFICE--
1 of .--