00080204 (2) CITY OF
nrvSIONO
INPERMIT CONTRACTOR INFORMATION:
BUii,DING�ffssHYDE AV RESPONSIBLE ROOFING IIT NO.
OWNER's +LTMEMANN CHARLOTTE M 918 N RF_NGSTORFF APPLICATION SOBDAT
;DONE: SANITARY NO. R
00 ARCHITECTIENGINF.ER: BUILDING PERMIT INFO
(650)969-6151 BLDG ELECT PLUMB MECH
I a , I I-1 =I LJ
Z 5 H= LICENSED CONTRACTOR'S DECLARATION Job Description
0
O a_C I hereby affna Thal 1 am licensed under prnvinim,of Chapter 9leommencing
5a. with Scoin0700(pol DIVlslaa3 of the❑usinese and l'ruleasions Code,nnJ n,y liocnnc
is In full force and coal.
i U License Class Lic.g
Date Cmnmmnr
3,a t; ARCHITECT'S DF,CIARYDON
l: O n 1 unfroarrd my plans,hull be wad as public records
oo Licemed Prole„land RE—ROOF
OWNER-BUILDER DECLARATION _
u� so 1 hereby affirm that I am exanpi from the Contractor's License Law for the
t z following reason.(Section 7031.5.Bu.si a,s and Professions Code:Any city or county
E F C which requires a pcm;it to construct.alter,improve,demolish,lir repair any structure
4.3prin If,lomic1c, 1. d ' thepph mf :I0p n I 'g d.tomnent
m II Ip :apt. t, n P :arm c t t r L 1 wfcnamer`) . Sq. Ft. Floor Area Valuation
teatme g tot , 7I%Np of Division 3(if the BusinessIProfessions ale) - $5250
or that he is exempt therefrom and the bass for the alleged exemption.Any violation
Of
f Section 003 LSbany applicant for a permit subjects the applicant a civil
or penalty
nm moremp h,e hundred dollar,la5oh). pyf4... 00 Occupancy Type
❑1,o,owner or me propeny,or my employee, ,,If wages i s theb,ole,ompemmmn,
will do the work,and the strucmtc is not intended or offered(of,ale(See.eves, Required Inspections
Business and Profession,Code:The Contmcmr%License Law does not apply to an
r of property Who haild,or inmpmvcs thereon,and who dm,such work himxlif
or though his own employaa.provided that such impravemenn am no,intended or
offered for sale.If,however,the building or improvement is.sold within one year of
nnminiuu,me oasoc,huilder will time Ibe burden of proving ohm bo did no,build or
improve ter parpa,e Lac.), 305 — FRAME
01,as owner of the progeny.am exclusively convecting with licensed contraction to 307 — INSULATION
construct the project(Sec.70fL Business m and Professions CaleO The Contractor's
License Law does not apply an on of Property who codes or improves,human, 601 — ROOF TEAR OFF
and who Conflicts ter salt Projects with n comm„orfs)licensed pamuead In the
Commentrs License Law. 602 — ROOF PLYWOOD NAIL
❑l am exempt under Sec. ,B&1'C for this reason 603 — ROOF BATTENS
OwnefDa1O 604 — ROOF IN—PROGRESS
WORKER'S COMPENSATION DECLARATION
I hereby aflimm tinder penally of perjury line of the following declarations:
w 1 have and will maintain a Certificate of Consent to self-insure for Worker's ~
Compensation, as provided for by Section 37W of ,he Lunn Codc for the
Performance of the work for which this permit is issued.❑1 have and will maintain Worker's Compensutlon Inwmme,nsrgnircd by Sectionlar 371q of the Labor Code,for the Performance of the vend for which this permit is370).My Workers Compensatie perfomance of th work for whichfoundertis _}9jIyIL
Carrier Policy No.:
CERI'IIdCAT10N OF Ii%I?MPTION PROM WORKIiRS'
COMPENSANON INSURANCE
(This section need not he completed if the permit is for one hundred dollars
1$100)or less.)
I certify that in the I'erformmsc of,he work,lir which this permit is issued.I
shall no,nnploy any person in any mon ter so as am hecnme subject In the Wnderi
nmpcnatlo .of Cal ifomia.Doe
pphcant
NOTICE TO APPI 'ANT:If after making,his CenibeaEmanprion,you should
become subjecrto the Wall Compensation pmvisinm a Labor Code,you must
;Q forthwith comply with such aawi,ions or this permit had be deemed revoked.
F y .CONS9'ROC)'[ON LENDING AGENCY
a > 1 hereby affirm that mere is a conaaactiun lending agency for the performance
of he work for which his Penni,is issued(Sec.30OD.Civ.C.)
L ❑ Lander',Name
Lender,Address, '
V 1...ifythat l hi recarl hisapplicamn aM.wane thutde cMwc information is
correct.1 agree to comply with all city and county ordinances and state laws relating
Q U to building construction,and hereby authorize representatives of his city to enter upon
;a, W the above-mentioned pmpcny far impenion parfums.
[r CL (We)agree to sore,indemni fy and keep hannlOw the City of Capenino against
I� TA hall litic,,juagmvus,calls and expenms which nay in any way amrm Itgainxt,aid -
t> Z Cityin coniatenceol he grunting ofthis perun 30-0
"t AP LICANT UNDERSTANDS AND WILL COMPLY WFH ALL NON-POINT O
Ila P REGulAT1oNS. Issued by:J!� Date
�pe,�,,,,�ur 5 30 au
.gnamre dA�anl/Cnntmctm Dave Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ormmmNdldingisappom,Inreorhandleharardousmntedal Type of Roof
a,dehncd by the CuPenino Municipal Code.Chapter 9.12,and the Thai and Sam y
Cahn Section2 532fa)7
o YO, 0N All roofs shall be inspected prior to any roofing material being installed.
Will meapplicanl orfuture htidd'umoscmand tae ecaimantordo,iea,which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air cou amicuroN u,dcfned by the Bay Arca Air pndhy Manageamnt
District^ all new materials for inspection. Applicant understands and will comply with
0 YO, 0N all non-point source regulations.
v1 have read he hazardous materials requirements under Chapter 6.95 of he
Cali linnla Bruhn&Safety Code,Sections 25505,25533 and 25534.1 carerswnd mal m
il'the tin ilding does oat currently half a tenant,Fault ban,responsibility to ramify the
necupam of the requimnmenu which all,,be ten prior to ism ins of a Certificate of /./.PGA�G�f= �” 4.5
upancy. 33006 Signature of Applicant (/ Date
Owner lir out rzea agent Dam All roof coverings to he Class "B" or better
OFFICE