01010005 (2) OF DIV;N
RTNO
I BUILDING PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: ""M10005
10452 SCENIC CL
OWNER'S NAME. /r AI'r1..LC5\T�I6yJ/ly bo 1
_ CAROLINE MA (v/_ L'1 C CG
HONE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
a ANCtlI rIiCT/ENGINEER: IILDG ELF,CIPLUMB MECH
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¢mow I-1 t=1 I"_I 1=1
O y j LICENSIiII cUNTHAcrGH'$DECLARATION Job Description
jy I homey arGim 111,11111,11Ain liemued nndrr Proviaioin u1 ChaPmr 9(auum,cncing
mi-w wimnsa,int,n7txalorDiv'i.xi.,mt3nfinenu.xinee.awvr..anxinasCode,and any lue-cREPLACE WINDOWS/ REMODEL KITCHEN
¢ g j is in full force and ef&et.
x ccs¢ Licmaxc Class Lie.R
t O a o Dam Conten...
ARCHITECI"S DECLARATION
-pYpY'=�g 1 J .I J my pins.hall tossed phi Js
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Lwn IIIom.:
N=an 1 hereby affinn that I am exanipt from the C I hili': : I for the /
C Z,Y which y fS din 9o1Ls B ' r. 1 I x Cal A y co, r n,utam r)
toSo wM1icb)isrequires aIannitc.also re cmnxWe,pplicant forurr suhper iitt rie a'nanyxvuctum V
. rnorbils iemame.aoarnto the the,q,ions of rorwcnnennimablceo,Law smmmmrm
their befaliccnmit pmxaannome proId of the notes Licenxefc,,taas Cor9 Sq. Ft. Floor Area 11ion
co ingwidi Section 71xHt1 of lei a nlnf the Bux anti Pndux tx Csxlcl t�c0 d1
or Inst he 7 11.5 b out
applicant
and the burin it the subjects
the
d excmrnt nt,to Any t to,n ily
no
of Section SOILS by any dr d dolt lin a permit mhjuls me applicum m a civil penahy
.,r no,m„Ire than ices hundred anua,a a511n1. A PN Number Occupancy Type
1,d ownet orthe ndthe%,nrmy is nt ttwilewogcx eInuitotic cn(See. don.
3570701.0. 00
will do the xx'ork,and the ode: na is not intended Li or..Rented for snot apply 71W.
lwsmmxx and Promx Who ild,cr nc comrII meoll Law does not apply ro an Reqs red Inspections
m'pm,peny won nmmnx o nt1,i, ca mcrcon.and won dnex xmdt work nintxclr 101 — FOUNDAT IP
or through his own amployea.provided that such intpmvcnrtm'me not intended or '
,offered for ewe.If,bowa.cr, be budding or imrm.emenl is xnld within are year of 102 — PIERS
onrepletion,We owner-builder will have the burden of proving that he did not(wild or Pm,efompmpoeaorxwa.t. 103 — UFER
0 1,a%owner of the pmI am cxclu%ively contracting with licensed commicam,to, 104 -- REBRR
Lm:auo the Projnd tSac,7043,110x3...and Pn fesainax CtJea'mc Contractor's
icanra Law&ex nnl apply.an owner or pmopeny who 6.114 or nuileve10mmoin 105 — ANCHOR BOLTS
and who contracts lin such pencetx wish a cuumactortsl lianw•d punumd to the
Cnnoaclors umm„m106 — SEWER 8' WATER
❑laimi ex• ,aim rsw B K PC hordes reason 202 '— UNDERFLOOR PLUMBING
°wnef D"e �� 203 — UNDERFLOOR MECHANICAL
ti ODA11'Dan ATIDNI)I:DL2i\-% 0 1N �-
utcrenyammnutwcapenaltrofperjmynnemmnu,unwingdeemrellm,it.: 204 — UNDERFLOOR FRAME
❑ 1 have and will maintain a Ceninan of Consent m elf-insole for Workers 205 — UNDERFLOOR INSULATION
Cm,q,en.aion. its provided four by Section 3700 at me Lmmr Code, ter Ina 301 — ROUGH PLUMBING
FeHorntanec of the work Int which Ibis Nahid,is issued.
❑l have and will nimmaio Workers Comnrcn..:nion lmurance,as marvi,ed by Section 302 — TIIB 8 OR SHOWER
370 mime Lana,Code.Int it,,p,donno my of the work for.1iml,Jac Iwnttil ix 303 — ROUGH MECHANICAL
issued.My Worker's Confen.micn Insomniac carrier and Policy number are:
ramie. 304 — ROUGH ELECTRICRL
Policy No,.
COMO IIICA'I'ION OF LKEM VI ION PRAM WORKERS' 305 — FRAME
COMPENSATION INSURANCE
306 — HOEDOWNS
fntir...0omtn«diimla,co..tpleleait the perodis lot mlohundred dnuan
l307 — INSULATION
Ixan nr hies)
I vie that in the performance of the work for which this pcm n is issued,1 308 — SHEET ROCK
'hall notempL'y Amy panne In any manner nu a.m becoute o,aacl m the Worker'
Comitperenifon Law,orCale"Inia.Date 309 — EXTERIOR LATH
Applicant
NOTICE TO APPLICAN'r It,after staking this Cenifalc nfffxemptinn.you should 310 — INTERIOR LATH
Z
wn
to ..;.I.b,,,t ,,the Worker'Cunipmtxmlun Pmviaiunx ur the Lubar Cady yon nnnl
Z
0 ronnw�ith<mtqrlywith such proki,iin.orthi.xpcluilxbmlbeJec,amdrevoked
31.1. — SCRATCH COR'
CONSTRUn'ION LENDING AGENCY� 313 — ROOF NAIL> thenay;drm,dtmmmmisil.o..wmctioncadh"agamy rortl,apeirmmam, 501 — FINAL ELECTRICAL ENERGY
of the work for which this hammil i.x i..uad see.3007.Civ.C.1
0 z 1sN1cr' Name 5022 — FINAL PLUMBING ENERGY
Lenders Andres.
'U O 1 centify that I have mad this application and state that the above infournotion is 503 — FINAL MECHANICAL ENERGY
Rx E• corset.I agree to comply with all city and county ordinances and state laws reaming 504 — FINAL BUILDING EN
O U In bund log mnnxnowtiem;ual thereby amhorira mpmmxcinnlivewl inn city to Hoer a,m
» heabove.manumadpmpcnyl„minshconattarro•c., 505 — FINAL ELECTRICAL
f” L (We)agree to sme.indemnity and kcep harmittr the City of Cupeninn against
V, liabilimio,judgments,vuoty and experi which may in any way aeemm against.aid 506 — GAS TEST
U 2 City in cnmeguence mate gnm,ing of mix pcnnit.
r SOUNCEAPPLICANT UULAT NARDSANDWILLCOMPLYWITHALLN'oOZ% Issuedby:507 — FINRL PLUMBING Date I� Z"LI/
R7 . FINAL MECHANIEHL
ligntilum n mph iennIA;^ae or !/ Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE S 9 — FINRL GRADE
Will the applicant inn future nnildmgoccnl,:rd,,.•or handle hYmJan,encrum w Type of R 3
as Jeli ned by the Cul,eninu Municipal Cook.Chapter 9,12.and the i leahh tend Safety 0 — FINAL PLANNING
Code,Section 25532141: �1 �c1,N IlwiOr�P's��Vo hQW g .
oY°s rye?'" All roofs s I�+beins 1LItl1 1 Il 11 o mR1iRCrial beim installed.
Will theapplicant or l inure building mccopant axe cgnitpntcn,or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
,mil limudoux tem
ter ono tinax as mined by the Bay Arca nu Quality M;ntagemm�l
Dixtderr all new materials for inspection. Applicant understands and will comply with
oyes KNo all non-point source regulations.
1 have mini the haraalnux milermlx reguimnmmx under Chapter b1/5 nl Inc
California Henith A Safety Chic,Sections 255115.]5533 and 25534.1 undemand that
ifthc bilding does not commonly hav atenant.man it in my rttpan%dlimy at notify the
uupnni of the re ......tic weld i,mo he ninl prior In iaxmmce of a Cenieeatm of
Data 1` f 2 Signature ol'Applicant Date
uwne.m 4nJinmum 4 'D,O �I All roof coverings to be Class "B”or better
OFFICE