01100076 (2) OF
CI BBUILDIING DIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO
23655 OAK VALLEY RD 01100076
OWNER'S NAME: APPLICATION SUB DATE
Aft PHIL & DIANE OLSEN 10/10/2001
PHONE: SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
m C LDG LECf PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
y I ner<b art mm I am licenses under r Chapter! 9 a'nmmencin lob Descri tion
'y-rz,-° withsKti )of Division3onheBusme.sandProfeaaonsCode.mwmyB<ense ARBORS .
x� or<eande �, 1 FIN
5rews se as, Lit.#. ALE
3 I- Con a,
ARCHITECTS DECLARATION
L 01
vt I understand my plans shall be used as public m=onds DEC 2 6 2001
a
Rn O Licensed Professional
OWNER-BUILDER DECLARATION
-u =' I hereby athun that 1 am exempt from the Contractor's License Law for the BUILDING
F Z following reason.(Section 7031.5.Business and Professions CWe:Any city or county $15000
a4O which requires a permit to conumet,alter,improve,demolish,or repair any stronure
i3m prrotl nce.alaotequrrcsthe applicantf porn rg �• 3458.5 O�oP•®- - t
suc u a statement - --
matha 1 sed pursuant tai thb proviuo of the Cnmrumt.Ltt.eLaw(Chapter Cod) Valuation
(co 'n6wimSemumlmanand he bas J fthe le,edv a im.An xAmie) i'+i. 111 r�:. h`��'z.i l .)`' a .
of tbsi be rs eacnipt tray.,m and he basis for the coo ll d sem tma.Any it .)anon
-of Smion 1031.5 by any applicam for a permit subjens the applicant to a civil penalty
,or not more min,Bvenunarmaollom(asoo). 101APNV91*DATION +i"" Occupancy Type
_❑I.as owner Orme prolzny,or m)'employees with wages as weir sole compensation, 1 02 - PIERS
will-do the work,and the soucom is not intended or offered for sale(Sec:1014,
'Bbsiness and Professions Code The Contractor's License Law does not apply to an 103 - UFER Required Inspections
owner of progeny Who builds or improves thereon,and who does such work himself 104 _- REBAR _
or through his own employees.provided that such improvements arc not intended or _
offered for sale.IC however,the building or improvement is sow within arse year of 105 - ANCHOR BOLTS
rompletion,the owner-builder will have the burden of proving that he did not build or
mprovef,"inTaseofsale.). 106 - SEWER & WATER !
01,as ,;net of the property,a exclusively contmwing with licensWcmtmcmrs to 202 - UNDERFLOOR PLUMBING
Lomtruct the project(See.7044.Business and Pruressions Code.)The Contm<tors
icense law does not apply to an owner of propes cny who builds or improvthereon, 2 03 - UNDERFLOOR MECHANICAL
and who commucts.for such projects with a commends)licensed pursuant to the 2 04 -- UNDERFLOOR -FRAME -
Cammcrnrs License Law..
O l air,exempt under Sce. ,,B&P C forthis reason 205 - UNDERFLOOR' INSULATION
owner Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
Ihcreby effinn under penalty of perjury one of the following declarations:
303 - ROUGH MECHANICAL
0 1 have and will mammin a Ceniacate of Consent to selfinsure for Warkers 304 - ROUGH ELECTRICAL
Compensation, as,provided for by Section 31110 of the Labor Code, for lhe
perfarman<e of the wan:for which this permh is issued. 305 - FRAME
01 have ads will n;amtem Workers Compensau6no I m uma<e.as required by section 306 - HOLDOWNS
Bou f thela ead m l,edprm e f d ark r Inch th s pe it 307 - INSULATION
_ issued-M er'sC to In% nee carne -_ 11 Policy are pp 308 .SHE$TROCKficy "
r) NOFEXBMI'TIONFROLWOR—� 309 E}CTE`RIOR• LATH "
COMPENSATION INSURANCE
0.:- "INTERIOR -LATH
(Thu union need not be completed if the permit is hundred doliars 311 SCRA+FCH COAT '•1•'t -� I�.'
I codify that in the performpnce Of the work for which,thispermitis issued.I - 313 - ROOF- NAIL. �-' - .•.. -.. - -.
�tna11'not employ'any person in any manner so as m becomesubject to the Workers' 501 - FINAL EItCTRI CAL"ENERGY
CompcW,iaofCmi(prriia,Due
Applicant'
502 FINAL PLUMBING ENERGY
- - - -
'NOTICE TO APPLICANT:If,after making this Certificate of Exemption.gall-should
z become subjecuothe Worker's CompensoYmn provisionn of thea2503 — FINAL MECHANICAL ENERGY
p CWe,you'inust
OO rannadn<amplywimall<nprovismn.ormiapetmhsnanxdamearevoked. 504 - FINAL BUILDING ENERGYt _
^� '-tCONSTRUCTON LENDING AGENCY 505 - FINAL� ELECTRICAL ,,'> v." 1 hereby ufnmt thauhere'is a constmctivn lending agency for the performance - - '
/Z
of he work for whichthi.p<nnitisis...d!see.301Civ.,C.) ,' ; 506 GAS TEST Lind :Name 507 - FINAL PLUMBING
Le de :Add s
I cert fy ma l have mail this apyl Caron and state that the above information is 508 - FINAL MECHANICAL'
' W Oomi I agree to comply with all city and county ordinances and slam laws resting 509 - FINAL GRADE
.O U lob lag construction, dhereby outhmiremputsencrovettifliti,city emeru,sm 510 - FINAL PLANNING
thebymentioned!p p=ity for inspectionpurposes,.
iy (W) g los d lfy and keep hurl the City oftpenmo against 514 - FINAL PUBLIC WORK
14 liabilities,judgments, ¢ d expenseswhich may n any y ace a gain!saw
V'Z City consequence(if the gr t gof thisperm t'
s,wS(VRCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' Issued by: DffiC V
S(URCE REGULATIONS. "' ' it I"'� Y
Si(n t of ApplidantlCmtmetor' '"" .. " '..Dine:, Re-roofs
HAY.ARDOUS MATERIALS DISCLOSURE
lVdl Nc applic m w f tort buildin8 occupant owe w handle hmsrdwts mataral Type of Roof -. . -- -• - -. .•... .
as defined by lM1 Cupen M 'typal Cod< pte 9.12,end the Health end Safety yp , Y ,l•t;to y h a'3'x r b 4i'. ' •" •'
CWcB ton 25532OS i i x ' 1 af!'4it '4 1. ial:? t 5t1r !G r
_ yet;
. ..All roofs shall,be.inspected.prior to.any,roofing material being installed. .
rR.. Will the applicant orfuture building occupant use equipment ordevices which If a roof is insialledtwithout first obtaining an inspection; I agree to remove
emit hanrdous our contaminants as define by the Bay Arco Air Quality Management
Disuictl- all new materials for inspection., Applicant understands and will comply with
❑Yea , ON. all non-point source regulations. ,
"I,have rtatl the�hazudoui materials requirements urider'Chapter 6.95 of the
Plifvrnia Hulth&Safety Code,Secdom 25505.25533 and 25534.-1 understand that _
- if the building does not currently haves tenant.that it is my responsibility m notify the -
cupant of the,requir 'hich'mu"be met 5 issuance of n Cenip'ne of '
<duyxgoY. <m Signature of Applicant Date
0 retort nor Eagent " Date All roof coverings to be Class "B"or better
c ... y OFFICE