01060104 (2) OF
TINO
CI BUIL NG O
DIVISION PERMIT
iory CONTRACTOR INFORMATION:
BUILDING ADDRESS: ' PERMIT NO.
21103 LAVINA CT. 01060104
OWNER'S NAME: APPLICATION SUB DATE
DENNIS WONG 06/18/2001
PHONE: SANITARY NO. CONTROL NO.
o e zo ARCHITEC tENGINEER: BUILDING PERMIT INFO
w' BLDG ELECT PLUMB MECH
N< I I I --3 I_-1 I-'I
8 u= LICENSED CONTRACTOR'S DECLARATION Job Description
O z-0 1 hereby affirm nd
that 1 am licensed made,provisions of Chapter 9(commencing
fm�to with Section 9000)of Division 3 time Business and Professions Cada.and my license DEMO.
><s is In full force and effect.
zz License Class Lie.a
w 3 i', tr, Date Contractor
ARCHrfECT'S DECLARATION
O a 1 understand my plans dull be mond as public mcords
m�
80 Licensed Professional
OWNER-BUILDER DECLARATION
u I hereby affirm that I am[sempt from the Commnor's License Law for the
C a following reamn.(Section 7031.5.Business and Professions Costes:Any city or county $12500
a O which requires a permit m ennalmcl,alter,improve,demolish,or¢pair any structure
,a Ce:r proi4if 'P1li n ': 1f It tl 'P Ictcicu, pry
(coth0almg\svh Seu ouissant.70(i11.ific rf Diskirm 3 visions of of,he Business d rro�ss Unifier Code32 OI O �.UV a'. L'a; Valuation
or that he Is dcmpl marefrom'aad the baso far the all,,,d exemplum.Any viollumn
of Section 703 F.5 by any applicant for a permit subjects die applicant to a cavil penally
of am mere man rive hundred dollar,H65em1. NO INSPECT ONS Occupancy Type
°1,as no,of Ne property,m on,employees with wages as their sole camp[nvtion.
will do the work,and the structure is not intended or oR'n¢d for sale Sec.7004, Required Inspections
•Business aad'Pmfasions Cade:The Ctamorctor's License law does mol apply m an q "
owner of property Who builds or improves thereon,and who does such work himself
of through his.If.employes.provided that mesh improvements within
not neyeintended or
offorccompletion,
fon tile.IL howocr,the dulling or improvement of pray n sold within ane year of „
ionipl[li for the owner of sale.),will have the burden of proving alta he did nw build or '
mprov[for rarwa\[or m1e.a.
h as owner of the property.e�s¢lu.cively cummning wish licenv l commcmm to `
License
construct the project(See. to a.Business and Proproperty
who CMe:)The ves tmerors
andwho
Law dols not apply loan owner of property who builds se improves thereon. '
i.;. .ami whor's License
for.such prajeas.wi0 a commmogs)licensed pursuunt.m the .... . ._ .._ _. ._.... _ ... _,._..__.- -_ ..__ .. _. .___.... ._.. . .._.._ ._.
[I I arnors License Se
- � ❑tum exempt under Sec. � • -.R&PCfanhis mason � iDi � ,. „ '1:�I!.rel ,
Osvner��%�/Tte cyYC/p'l
' OAR ET( R'S COh1POMP t1i V5ATIOfJ DF,CLARrITION
1 hereby affirm under penally of perjury one of the following declamlions:
• O 1 have and will nuiaGin'o CcniOcai[ of Cei m self-room for Workds �Q
Compensation, as provided for by Section 3700 of the Labor Code, for the
_ performance of the work for which this.permit its issued;,
°I have hod will maintain Worker's Cnm'penmtinn Iv...rea,as resorted by Section
37prof the Labor Code.for the performance of the work for which this permit is
issued.My Workers Compensation Insurance carrier and Policy number arc:
Crude, pcl,,No.:
CERTIFICATION OF E%EMPIION FROM WORKERS'' - _ r + . _ - •i
COMPENSATION INSURANCE'
(Thin Fcclion ncM os bocompincd if the permit is for ones hunNW dollar.\ � a:C;:l`.II!r•: 1:�'.� _ _ •
61001 Or las), �
ftcnifY ho"
in Ih[p[rformpncc of the work fm wht h thisP[mlil is issued,1 - .s L ,['.'I
shill not employ any;parson In any mumer so as to beconu subject m the Workers' ` '`I t
Compensation Laws of California.Data
Applmanl
NOTICE TO APPLICANT:IL after making thin C[nilicot[of Excmplion.you should
Q Obecome subject m the Work&,Cnmnspcomm mosi mo,estate Labor CM[,you must t
forthwith,amply with such p......mr,or this permit shall ho demned revoked.
' CONSTRUCTION LENDING AGENCY
"I hereby uliithis thcrt inrnnswmino lendlag agency for the performance
the for whichch this permi(is ¢
issue)IS : 09
37.Civ.C.1
Ler',N
'
_D,Z Lender's Address'
U`0 I eenify thm bun rcaJ this uppllcmion and sone Ihm the above information is
ris [�. COIR<I.I agree to comply with all city and county ordinances and dare laws relating
C.0 tobuilding constrociaor.andhereby runhodoe representatives of ths city to enter upon p
the b i ad P p and p cl n limit
.
E.t 6s (W) greet < rl f, ad k p n rmle. Iha City f Caption.
against
rn liah I t judgments. 1. I pc m which may in any waytarmeb against said
V.Z Cay :e4. of theY g fthispv t
SOURCE ANTGULrRSVS\DS AND WILL COMPLY WITH ALL ON POINT Issued by:
agnmumor Applica /Commelor . - - Da - Re-roofs
HAZARDOUS_MATERIALS DISCLOSURE
Will the applicant or future biildingaxupamsome orhandle haszrdousmaterial Type of Roof .._.-------_ -
as l rn d by th Cupen Mm aipal Cod Charter 9.12, d the Health and Safety - __ .-.._
, .-,
Coale.Section2553211 sl \ r , s • 1, . k .l 1-` ;
OYe Irl`°." All roofs.shall be inspected prior to.any_roofing material being installed.
AM the opplic t r building p m use ca.unpancia d vias,which If a roof is installed without first obtaining an inspection;I agi`ee'to remove
anat hazardous artacontaminants defined by theBay Arca\ Quality Manage rmat
Di..o°Y[ No all new materials for inspection. Applicant understands and will comply with
all non-point source regulations. i . -
`` 1 have road the hazardous materials rc'mocn,car'under Chapter b 95 of.in,
California Health&Safety CMB Sections 25505:23533 and 25534.1 understand that
irshe building docs not currently hmx a teem,that it is my responsibility to notify the -
occupant of the royuir meals which must be mei prior to of a Cenilicate of
Occuprmay c Signature of Applicant Date
owner nr aanaori.m agent i^ _ 13at[ All roof coverings to be Class "B"or better
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. . . __ OFFICE . . .._. ..