00110026 (2) CITmLDING DIVISION PERMIT CONTRACTOR INFORMATION: 1
BUILDING AD SSSEDWARE)'. AMI!iIs AND PERMIT NO. I L 1 -' 1- •
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OWNER'S NAME: - 92!599905 APPLICATION SUB DATE
ONE: • ' SANITARY NO. CONTROL NO.
p c z ARCHITECT/ENGINEER BUILDING PERMIT INFO
a-,E . •REMOVE EXISTING R r8TO� Nf'r1t0#EA�TM '
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Z y i LICENSFD CONTRACTORS DECLARATION lob DeScrlpt n
Ifeach,.1firindoill' tl' W 1 p fCh pl 9(omn lig
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won Scotto 700(U r 3 f n Basin .d Prarac w - J my f n-
y 5 Is' r 11 r rc and f ie '•� 7 r/(�
5 N 6 Li Cla e Lim.# L, '
3 LL Unl _Ct O h ARCHITECT'. F.CLAI
os /1anr�e,land,n,plea-bell he use -rem It �/ '
Y ej
Licensed Ptnf clonal - ® -
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OWNER-BUILDER DECLARATION l
1 marvioumrmaunt stn,Business
Bam he Cananeloo e,Anycty. for the ,. $62c4
following i nwn.(Swoon 7031 5,Ba-eme-,nsuitro Ptnfdomels Cala:Any city.,,.only
SH ct which reynnes a permit p mw,mcl,alter,improve,demoh-h, file
repair nay fhomme
amine t
3P� Prior toslissicensed parocaltoThe owsiaaant toe Co puteil tofileasignadxmtemna
(that he commescingisit pSewunnolhe pif Usannf the he Business ndP Law(Chnpwr9 S`q. FifS. a �- Valuation
I,,tmma,cingwni,$fficam 70(g))(if Dl feesar t the Business PodAnys,Cade) ,
or teal io is exempt Ihcaflnm,rad the basis forihe alleged exemption.Any violation
ar seeliann than
5 v anyalilflwantdap fora permit subjects the applicant m o civil penvhy
at not more man oke M1aaareddmmrs(xsa). , . - APh'OrumberFRAME- Occupancy Type
❑I.a..wnaaftheprepenr.armyentployeaswithwogaa,Iheirof,compensadnn, 307 — INSULATTOsl .
will do the work,unit the commie is not intended(it ofDrcot for_cele(Sae.90,14. F 01 — ROOPe TiE€bRnEdi ons
Business and Professions Code The Contractor's La,i Law does nal apply m an t] 0
oWinrofoppelyWho haikka,i..pro.e=mercon,and whadoes suchwork himself F-102 — ROOF PLYWOOD hIRTL..
mugh his own employees.provided that such l,nprovements are not intended or F-102 - _
offered for-ale.If,naweve.the building or improvement is,sold within one year of I603 — ROOF BATTENS
impletion,the ownermaiidec will have the burden of proving that he did not build or '
Completion.the 60/A ROOF IN—PROGRESS
❑I,as owner of the property,arn exclusively contracting wan licensed contractors to - -,income,(he p.,,at(Sec.9044,Business and Profession,Coal The Conaomor's .,
License Law docs not apply w on ownerof properly who builds or Improves flounce, -
and who eon me,for such prnjrets with a conmmtor(s)licensed pormnm to the -
ContmcwVsLi ...Low,
❑I ant exempt under See .B A,PC for,his reason
Owner Dote
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofperjury auto ofihe following declarations: ,
I have and will n,ninlaln o Certificate of Consent to self-insure for Worker's
Corapenndoq us pravidal far by Section 3700 of the Labor Code, tiff the -
pedannince of the.,,,it fi,r which this permil is issued. - '
R- 1 have and will maintain Worker's Compensation Insurance,as required by Section '
39 1 of the Lunar Code,for the performance of the work for which this peradl is
issued.MyCWorkers Com///p$$$���,,,n aaoo Insurance carrier and Policy number are:
Carrier.`•+ Policy TION(��11�1-00- Q
CERTIFICATION F F.%Eb1PTiON FROM WORKERS'
COM ENSATION INSURANCE
(This section need not he completed if the pennil is for one hundred dollars -
(5100)on Ices.)
I comfy the,in the performance of the work 1'ai wh'mh tris pennil is"add I
shall not employ any person in any manner so as to become subject to the Workers
Compensation Law,of Califinorm.Data
Applicant - -
NOTICE TO APPLICAN'C It,aOnmaking this Cenlflcum of Exemption,you should _
become-ubject to Ilse Worker's Compensation Prov smis of the Labor Cole,you must
Q fanhwithu.reply with such pros-inn,or this per,nitseall be deemed revoked
z .
E" M CONSTRUCTION LENDING AGENCY
a 1 hereby or wBnn that throe Iss cored(Sec. Icnteing agency for the performance
W
of work for which this pcnnh is issnce(Sec.3047,Civ.CJ
Q
Leaders Name
Lariat's Address
U O 1 cwiify that I have read this apprcutinn and eauc that the above mfaif matium is .
4ti [y conduct.1 agree to comply with all city and calmly ordinances and state laws relating
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to building eansmuc(,omand hereby authorize representatives of this city le enter upon -
pWI he ad,we-ancienerelp party f ' .pe( per,ows,
„ (W) g e.oor,inderniand,andkeep l I ss the C'tyaf Cupenmo against
CO) liabilities,
V j dyment' cat,and expenses esh h may in any way accrue against said
City to duaw"mone e
w"Tion. W
APPLICANT,UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issuedb Dat
SOURCE REGULATIONS Y•; 01
Squalureaf Applice.07mufaeaa - Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Wiutheapplicantorfutureladlmogcca;Pam"tarearhandlebrondaismaterial Type of Rho ,
as defined by the CaTeninn Municipal Code,Chapter 9.12,and the Health suit Sa@ty
Code,Section 25592(x)^
C1 Yes ❑rva - All roofs shall be inspected prior to any roofing material being installed..
Will the applicant or futures ingoecup:m,ma, uguarlordwecesisbid, If a roof is installed without first obtaining an inspection, I agree to remove
tit h,,u as,air ccomponents as defined by the Bay Area Air Quality Management
a-tree - amaterials for inspection. Applicant understands and will comply with
°Ya- °N all non-. 'n .ource also
1 have reed fee ba-d!.......am r I adsy i I on Italian' J Cibpt fi.C�.dthm
V Y ' I r' O
tom v Health A,Safety C J Section,25505 5533 ad 25534 I d Vifiha 'dilg dnasn t n illy ho' et and Ibal'l 1.n(YrcP n.b 1'lytacap.tm the rcgn re rents wheh n t pr nr to i-su:nc_e of Cin _
Occup
1 e o Date
5411 nerd agent Data All roof coverings.to be Class `B'•or better
OFFICE