00100180 (2) CITY OF DVSONo
BUILDING IIPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PIiRMIT NO.
OWNER'S NAME: AI'PLICAT •
10724 FARALLONE DR fB��P�1�T80
ONE:
RAOHAVAN IANIRYP8-/2E/LW ND'
O O AHCHI'I'ECTIIiNCINIiIiR: BUILDING PF.RMI'f INFO '
<CWi BLDG El I' PLUMB MECH
S = LICENSED CONI'RACI'OR'S DECLAkATION Ilpn
Job DesArl
Q = 1 hereby allirm that lam licensed under provisionsof Cleopatra b oul too p
with S1 i,,.7(NNB al Divisian3nfthe l{ue'inens and Pndcs',inns Q�pxle,nntl myliccnse � -
Y g in full farce and cflmt 240
oU Liren Clss �e__ Lic.p
3 0 Dan:LQt}[.P• oo r-mJnt"o,
AROIfl he ma public
f gunderstandn,ypmm,nmin aeda,pabliertenms y AC UNIT/WATER HEATER
y=y O is LlaensM Prolnz,onal /
OWNER-BUILDER R BUIL UI R DECI AkxrION
is I hereby It m 'but70 nes nth C.....t L L for the � Z
E followingreason.(Stanfill]ool 5 ❑ f J 1 f .C , y lY .....y
X whl 4 are I t n. - t II F1' J I':I p y a uurc
3Q pct; was cense rasa require thcapplemt me Contractile,
onnotele-iiol,(Calemem
that heincingw•Jpurtanmtnmepnwi..%nnen3ofthBu„no,Aand.el.awon,Cde) S FL Floor Area
(commencing asah, lulan70n ision Profession,Cede) 9 Valuation
ar that he 7 comp,tmy Ppl nntl the basis for the allege)cxcmption.Any t Penalty
of Section]W LS by any applicam Iirr a permit subjects the applicant m a civil penalty
of mare than rive handed dollars($5M), APN Number - Occu ap Ey p e
❑1,as nwacrnf do,;Io,cnv,or my employees with wagon as neo-sale compene:nian. _ y �
will do the work,and the swilure is nal intended lir nn'amd for sole(Sec 7044,
Business and Pmfessinn,Cale:The Contractors License Law ones not apply Iu at - squired Inspections
owner of propenr Who builds or unloose,thereon,and x ho does such work himself 3693,403 ��
or through his own employ«s.pmeided that such improve rc us am not intended it
offer for sale.If,however.Ne building ar improvement in cold within one year of
impletion,the owner-builder will have the burden of proving that he did not build or
aromatic in, .,,,a.1sale) 303 — ROUGH MECHANICAL
01.a,nw„ernnhe„rnpeny.ma eselolvely em,tmeting will,reaaced enmrarn,an 304 — ROUGH ELECTRICAL
Licen,.etruct roe project(Sea.71.4,1{mme,e ro P.y hr,b Cttleo Theeantmrmrs 505 — FINAL ELECTRICAL
se Law met not apply man owner of prnpenr xor huiics se improves tbercon.
and who cnmme¢for such projat,wish u commonr(M Iiccn.aJ pursuem to the
Condoner.",License Law. 508 — FINAL MECHANICAL
❑1 am exempt ander Sec. .II&P C foothill often.
own« uam
WORKER'S COMPENSATION DECLAkAI'ION s
I hereby union undo penally a1'Pr+jory ane of life following Jeelarsexa s:
1 have awl will Inaimain a Ceniliaate of Cams., 11 -If imare far Wo,mpematin) as Provided for by Section 37of the Labor Code. (lir the
rtmm�a
pence nf,he work for which this pennon is issued.
❑I have and w19 maintain Worker's Compensation Insurance,its rcynircd by Section _
371N1 of the lath,`Code, the peefo onalle of the wad fur which this permil is
loard,My Workers G,mcprmwlim,blsueunee cameo and Policy aumter me:
Curricr�T�TY.�__✓�Jp Polity No.: IS37I07'Q�
AERr11gCAT10N OF I:KEMFFION FROM WORKEkS'
COMPENSATION INSURANCE
(This section need not be o uilucted if the permit is for one hundred dollars
(E Ilio)lir less)
I ready drift in the performance of the wank for which Iris permit is issued,I
ry -
shall not employ'Inv pc ,n in anY'lam,ner so as,o become subject to te Wohrkers'
Compensation Lows of California.Dade
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
Z become subject it,the Workers Compsnsuwm provisions of the Labor Code,you must
O O darNwith comply with such pnwisim,s ar this permil shill he domed revoked.
r
h COt dale is a foN1forion LENDING AGENCYof _
1 hereby ullinn this there is n hated(Sawn Irndin6 agency for the Performance
Lethe work for which Iris pmni,is issued(Sec.309].Civ.C.)
y z
Leader',Name
z LenJer'a Address
O
correct,
rectify that I have rend this;,pplication:md„ate that the abavc information is
Ir rrect,I agree m..nnply with ak city and moody ordinances,trod state laws rcluling
O V ohailding enn,tractim,,uml hereby uoloontc n,oa,amedvr,,do,eitym emw npon
Ln liabilities-memmaeJ propcardalnsp«ti which may
�.I
Q. (ISO agree msnvc.indminifylmd Aral humor the City of Culmina against
L-I V1 City in co judgments,cents and expenses which may in my way creme against suiA
C.7 7
City in CansTUND°(the gem of Dthispe CO
SOURCE REGULERSTA UWILL COMPLY WITH ALL NON POINT �/�
SOURCE REGULATIONS. Issued by: Date (/ IAOI•
Signamm ol'Applic GAiI tactor Disc -
HALARDOUS MAIdors,lt1ALN DISCLOSURE � Re-roofs
Will yh he Utcam or future huilding e,Chapter
atort or find
the Health
ad Sluriry Type of Roof
as de.Sed by the(Lpcninn Municipal Cntle.Chapter 9.12,and the Heuhh and Sa(my
Code.Section 25532(a)”
0 Via, All roofs shall be inspected prior to any roofing material being installed.
Will thealf”eamo home hZIMin aroupam um eyuipmem n`devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous mr enntmninlant,m defined by the Bay Arca Air Quality M.aagamm�t
)Anil” - �f all new materials for inspection. Applicant understands and will comply with
❑Yes P1°" '
all non-point source regulations.
1 have read the harallom matcdaH requirements made`Chapter 6.95 of the
California Health k Safety Code,Sections 25505.25533 am125534.I understand that
if the huilding docs not currently have a around.that it is my re,pmsibility m notify the'
sec pant of tore rtquiremcms which must Be filen prior m motion, of a Cectiticaea of
O u
Signature of Applicant Date
U, raramm�riae agc.l �3ae All roof coverings to be Class "B"or better
OFFICE