01110083 (2) CITYBUI DNO
I G DIIVIISCUPESIIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10501 N PORTAL AV HOT WATER INC 01110083
OWNER'S NAME: APPLICATION SUB DATE
MURRAY W SCOTT 2531 GRACELAND AVE 11/19/2001
PHONE: SANITARY NO. CONTROL NO.
(650) 298-8494
tZO O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
w F BLDG ELECT PLUMB MECH
a i LJ LJ L__J L_I
LICENSED CONTRACTOR'S DECLARATION
5 Jb Description
Z=M— I,im 70 0).f rvi I am time B under provmons of do apter Code.
(commencing
:n[—w Smdella )or Division 3oflhe Business and Pmferritins Code.and my lions REPLACE WATER HEATER.
f m y in roll force anJ.ellam. 9
z m a n CI ` •J Lic.p
Dale �5 SDECLA FINA LED
13 ARCHITEe are DECLARAT N
1 undersold my plane,hall he axed as public records
o o aroed Prafes.iowl MAR 01 2002
OWNER-exempt from he Connector
I hereby affirm hm 1 Om exempt from me Commnor's Li¢nse Law!w the
C?< fallowing rt n.(earri t ]OJLQ Roemer, and demolish.
orm Cade:Any oily m county $500
aw
Y s O which requires a permit m nmamet,alcor,improve,tlemolish,or repair any nmaurt
3$ riaolnenapmlep .osoe rsawr . Rim iwla
t u q theapplicant for such pem,iuo file asgned statementi ';e3• � pprpL' Valuation
(commencing with Section]000)of Division J of the Business and Pro&mons Cradet _
Or that rte is cxcmm mcrtfrom and 0e has..for the alleged exemption.Any violation
or Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty
m
notmorethanfivehundreddollars(S500) 50�,PNlx�ltj,�XL PLUMBI ENERGPccupancyType
O 1.as owner of the property.or my amp cry a,with wage,us thdr,ole eompenwtmn,
-will'do the work.and the nmcturc is not intended or offered for sale(See.]BM,
Business and Profession,Code The Contractor's License law does not apply to an 507 - FINAL P$FR+Ijy#4 pections,
caner of property Who builds or improves thereon.and who does such work himself
or Through his own employees.provided that such mponcepravcmenta are not intended or
offered ale.w nowuilde me banding tar urdenof prow is that he did
n-one year or
inupri for the owner-builder will have me burden or Droving that he ata not Wild or "
impnwe for narpaw or sale.7.
_ ❑Lasowner.(,he property,am Business and
Praa.ngwitlianxde Contractor's
ontrrnrsto _ sirs •t
omwm the pejen (Sec. to a,Business and Professions Cedea The improves
tin thereon,
,t
andUraniaWho
law does not apply m Mj owner of apropertyindications)
who solids m impmvea menton,
and who contracts for such projuu with a contmnor(s)licensed pursuant.m dm ._ . _. .___._ -__.. .... ... . .. .. _._ -. ._.. .._._-____._
Contractors piaena Law, _ .
❑lam exempt under Sec. ° :.B&PCfor his rcatn �^J I:., ^�•;'
Owner Dole
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty orperjury one oRhe following dedaruiom:
( ❑ 1 have and will maintain a Certificate of Consent to self insum for Worker's
Compenation, as provided for by Section 37M of the Labor Code, for the
_ pesfomunce of me work for which this permit is issuN.
❑1 he and will maintain Worker i Cumpenemiun Inwrunca,as inquired by Section
37 of the Labor Code,for the perfmmance ofme work for which this permit is
Omer: /�' , Hct Insurance comer and Pnlic numheram. _
T
I ed.My WWorkers<r's
as, 'mpcn ting Policy Na
CERTIFI .....,/S ��
C.
TION OF EXEMPTION mom,WORKERS 5" s�'r •:� � ;, :Yt'"'1;�'=JI' "% 5 r':Al t ,• t.•. �t,ll
••• .. COMPENSATION INSURANCE
fTh s action need not be completed if the permit Is for one hundred dollars
ISIIXI)or taro.)
. ,. .fa
1 employ
as .n the performance nn me work for which this permit,issued,I I•, � it ✓
shall nm employ any person in any manner t as to become subjat m me Worken'
Compcnatian Lows of California.Data
.NOTIant ranking c _ ..• pi_ ._ .::
NOTICETOAPo the Work:IL Con,emtion sCcnificom of Exemption. .-y uM1mulst -
hccomn subjem m the workers Compenmtmn pro a, hall ed Labor Cade.you mass
Q O forth hM1 ply wito� h p ,inns nr m s peon t shall be domed invoked.
._
�
(~ ti •" CONSTRUCTION LENDING AGENCY t" I
�a.> I hereby affirm that t1rets a connrummm leading agency for the performance
W tti of the work for which this permit is issued(Sec.309].Civ.CJ
QUnder's Name_L. .� _ . .- . -......,.. .�:_:�_.-:-
Under"Address '
C.).� I certify that 1 hate mad this application and state that me above information is '
summeur.I agree to comply with allcity and county ordinances and sum haws relating
O. to building ennstrrvimrn and hereby authorize representatives of this city to enter own
-W the Oso a-riern toned property for inspe ion.purpose,.,,
lit. 1 We)Ogen,m nave,indemnify and keep harmless the City-of Coleco..sourst
J`!) 1i. mines,JyyJJJaaaattdgmc.tx.cos¢and expenses which may in any way accrue against said
V z Cdin equentt
of the granting of this permit ,
APPL ,AbTUNDEASTAND2N ' WILLCONIPLYWITHALLN-
NODINT'' Issued by: Date
SOL' L
Will meaty_ o .Ns. - f'H,✓' / IS�fYI y'
cane manta "' um "y Re-roofs J
F
eta of App
HAZARDOUS MATERIALS DISCLOSURE
pl.Ea t mi f mnici,.l Co pant tore or hinad a hatHealth
a Safer l Type of Roof •- - --
as d f tl by the C pen n M " ipal Cad Chapter 9.12.a d the Neahh unci Safety .,
Code Section 2551'_(el t,• sill, .. •. ..1 I. I lir.? s i : . v a' i .. _ _ •'...t .
❑Yea,..... ..:'...ONo;t .�...' . .
f __All roofs shall be prior-to any roofing material being.installed..-,-
Will the applicant orfuwm building occupant usecquipmenl mull which If a roof is installeinspected d' iwithout first obtaining an inspection, I agree:to remove
emit haardous air contaminants as defined by the Bay Area Air Quality Management
District?vex - ,❑Nn - all new materials,for inspection;_Applicant understands_and will comply with
1' �, „ ,., . ., I , � I all ncri-point source regulahons.
1 e read the hazardous material q rcmems unde Chapmr 695 of me
@lifo a Health&Sdfety Chile,Sections 33505,35533 and 25519.1 understand that
'it I oildin docs not currently have it is bilis mnotif and
6 Y yresponsi Y y
pari of the fequimmenrs Bich tun be'mn prior m ixsunnce of a Cenifcue of
IXea°a°ry' Signature of Applicant Date
g PP All roof coverings to be Class 'Ba'or better -
heroramho' g
OFFICE ._ _. . .. . . _ . . ..