01110054 (2) TY
CI of c DIVIiSIIONNO
]BUILDING CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10065 SANTA CLARA AV DOYLE CUMMINGS PLUMBING 01110054
OWNER'S NAME: APPLICATION SUB DATE
Aft 6TIMACH ROBERT AND MARY R ET A 14311 BUCKNER DR 11/09/2001
� VHONF.. 4089234221 SANITARY NO. CONTROL NO.
O O ZZ ARCHITECT/ENGINEER: BUILDING PERMIT
LQ w 0 BLDG ELECT' U MF,CH
R a i IJ JI
LICENSED CONTRACTOR'S DECLARATION
5 y e h Rlnn tnal 1 am li,croea anger rcW t v aammene;n Job Description
i L_ rc y u proriniwns n per g
i <ctmorcrixigzr.,on3nf me Bmme.a:ma Prvfe,>mn.emle.arta for Eanse SEWER LINE .
mB futs a rr .t.
3 a ¢ .mcnsc Class _ Lic.a_� l &�
O a L'I Dae Commnnr Oea.r ...«+r«•
a ta i' ARCHITECT'S DECLARATION
1 untlersland my plans shall he uud as publle TI-i
I C C Licensed Professional
OWNER-BUILDER DECLARATION
=' I hereby airnu 1hwl 1.,it exnnpt trom the C.mmo or's Liaeme Law for the
C?afollowing reason.(Section 7031.5,Business and Professions Code:Any city or county $3200
Y x C which requires a pemtir to construct,when,improve,demolish,or repair any smart
uu
ad
iia- prror so its .uance also requires the applicant for such Permit to file a signed statement -----
thathq slkimdhur6a'mld We pirommus fmc Contractor's License Law Chapter r I•�,�� " qr t a Valuation(comm c e ohS Sir �000t fD "D.vison3 1IheB 'nue end Professions Code)
or that he is csempr thimfroahand the basis Tor the alleged aiimplam.Any violation
of Senior 7031.5 by any applicant fora hermit subjects the applieam m e civil pouchy
of not mom than five hundred dollars(s5W). 106PIvN'SEtVER & WATE "T", ") Occupancy Type
❑1,m owner of the property,or my employees with wages as their sole cmnpenution,
will do the work. oil the motion,is via fiamch l or offered sale(Sec.704,1:' 3 O 1 — ROUGH PIB 81Yb�ipec[ions "
Businus'and Professions Code:The Contractor's License Law docs not apply to an `•
owner of pmpeny Who builds or improves thereon,and who does such work himself 302 — TUB & OR SHOWER_ _ _
__or through his own empinyeee,pnmWed Info such improvements ore nor intended nr
offered for sale:If,however:te hbuilding or impios su
vemenl is within one year of - - -— - '"' _ _... ._..._. ._ ._
completion,the owner-builder will have the Widen of proving that he did not Wild or 502 - FINAL PLUMBING 'ENERGY'- .
improve for purpose of gale.)..--- — ...- -- -. ... ..._ 506 - GAS TEST ----- - — 17-_7
- --- --
: . ❑a.asmv....nrthepratinit,am<a.ismdyemomr1ingwithreenudcontractors to _507 _ —FINAL--PLUMBING' :;(`
L m t undo Sec ureas d Professions Code:)The improves
thereon.
const
e tt e project such vier of property who W C m improve thereon.s
1 '
Contract.""iris tory .with a contractors)
conatrvcl I prnje (Sec.law,Bu
Law does oma I to an ow
projects co r or ..
C w S Littnse Law.
❑lam exe � � � '" � ��' ;B&PCfor this mason
Owner' 'Dae
• <-- , WORKER'S COMPENSATION DECLARATION /
I hereby affirm under perulty of perjury woe of the following declarations:
1100 1 have and will maintain a Certificate of&rn cot to ulginsum for Worker's
Compensation, as provided tot by Section 3700 of the Labor Code, for the
j¢formarne of the work for which this permit is issued.
❑1 ho'' 6d will mai main Worker's Compenmtion Imurance,ad required by Section
37 the Labor Code,for the performance of the work for which this Pemdt,is
s d.My W kcr s Coryt�pen.5i on Insurance caricr and Policy number are:
: .. ' sariicr+ 9` ' °Poliiy No ]SjOq��(7^ n I
.J. . __... _.. . . ..
\ .. ` i. tj.i,�'lss t` :s .r � \_•L.':1! tll
,„C-RTFICAN E KE0.S'
COMPENSATION INSURANCE;'v.
1, - ... '
I.
tai is rrTnis section need not tie comylemd if the permit is for one hundred dollar,
a 100)or less.) l
I ri fy th t n the pert nth k f h nth pe i ..ued l •. ._ «.... .. •••'".• - s 4'I r.°1.-_. t ._.. .. . ..._ .....
shall not employ anypenan to any manner so as to become subject to the Workers r
Compensation laws of California.Date
...Applicant ..
NOTICE TO APPLICANT:If,after making this Cenificare of E cmption,you should "^
— O s subjecte W'orkes Compensation provisions of the Labor Code,you must
fnnhw 1I thcrcbylyRhth g agency f the
fxN
z' such this permit bed d kd
fZ" r0 CONSTRUCTION LENDING AGENCY"' - "
That there w t 1 dncc
sof The' irk for which th Iw m t s ed(Sec 3007 Ci C) s
r�.r.. ... ..LL. _ __ _... _ _ ._. . --------
0.
._,—.. .... .._. .. ... _.._. ..
'Lenders Nume__ _. .. s. _ , _.. L ,._ ,,.
7 Z Isnaers'Addre::'- _ ..
G
t.7 � leerily that have read this application and sum that the above information is
'd&Teat.1 verse m comply with all,city and county ordinances and state laws relating
Q (� tobuildiny constrvetidn:and hereby auttionze'rtpdsimatives of this city to enter upon
above-ntemiois property for impection pur,,s, s.,.
p. 1 Wq agree ts save,indemnify and keep h may in the Cita of com against
against
U'Zliabilitiesit judgments,cot and raper.,wh h may any way g rest,said
V. Z City i q c<of the g t n8 f thi.i pe h.
A (CANT UNDERSTANDS D WILLCOMPLY WITH ALLNONPOINT' IssuedbY: —V
U0.CF REG' IONS )' '>'y
S' of APPlicanr/C mracto D m; �' Re-tOOfs
&rnwler heCuper�� Mur paatcoga�,Chpte.`9lz�a he�llthaddsee�1 Type of Roof-
as --
FIA7ARDOUS MATERIALS DISCLOSURE -
y ' , p
Code S n on 2553 t )7 - ,. - : ' , . .•,
.; . .__.All roofs shall be,inspected prior to.any roofing.material.being installed. _... .
Willdieapplicamor future building revolution use equipment or devices which If a roof is installed'without first obtaining an inspection, I agree'tcremove
emir lr i dmn air cnnt..front,as defined by the Bay Area Air Quality Management
Disinter? - _ all new materials for inspection. Applicant,understands and will comply with.
0y` 0 -point non-point source regulations. ,
I h x mad the hazed us mam"als le,.imomid,under ehapm 1695 of Ne _
Califomia Health&So(eI Code:Sections 25505:25533 and 35534.1 understand that -
;ir buil ding does not currently have a tenant,that it is my responsibility to notify the
i c an of iiimnmmnt which must W met pi.:m m issuance of,.Certificate of
p' p ( Signature of Applicant Date
on !aanod.e,agml-:':, • ;�,;� . Dae All roof coverings to be Class "B" or better
.. _ .. . ....,. ... .. _':: .' I. � _. .,._. .••_ OFFICE '