02040008 (2) CI BUILDINGmyON RTPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
6212 SHADYGROVE DR 02040008
OWNER'S NAME: APPLICATION SUB DATE
ESTHED YANG 04/02/2002
PHONE: SANITARY NO. CONTROL NO.
ez ARCHITECf/ENGINER: BUILDING PLIVol r INPO
F.z 0 C BLDG ELECT PLUMB MECH
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w2 LICENSED CONTRACTOR'S DECLARATION Job Description
z=o I,ma70.Ram that I am licensed under previsions of Chapter 9(commencing p
„C,� witns<ea°InoomlorDroLion3nnheaut�nlx.anaPmresxmnaCode.altdmyfi<emse CLEAR OUT ACCESS SEWER.
imyn ' Tautea ana erre< liC
c m0 i u 4Ts Lic..
4 fie C.aamcor e .
mn
i 3 u G AHCHITECI"S DEC ATION
u O a 1 dcrnun� vh a aIWILx used ns limit records
Limnscd Pndessinna�
- m w OIUILDER DECLARATION
1 hereby.(lien the,atI ma1. .Burin s�n the Can tmes Cos License Law,for the
which moreason.(ern 7U31.5.Business improve.
Professions Code:Any city orruunry $850
I x O which rcquirts n perms to construe.ober,improve,demolish,ar repot(.ny structure
V
Pfarm lift oaten the fthc suchFrmr s.fit signcdstmememther
a3°O "pr'ortoe issmt al.nrequires the a..in mfor suchpecou, filen
m{a pSe a -p Ormnso screw lChepmr9 S �,,<,Dpr�a Valuation
(commencing xnh Semiont]n of Division3n 'he Business and Pmr<..ions Coo<) `Oti.'� �3rr�4Ff:( C4"'.::-W:9�'ti�. 'E ;ilk.
ei that he is exempt theiefmin end the basis for the alllgetl exemption.Any violation - -
of Stttion]031.5 by any applicaa fur a permit rid of the apphoam e.a civil penalry-
'of no(mine man five hundred dollars($500). 10(5PN '9� & WATER .'.'oro. Occupancy Type
❑I,as owner or the pmpeny,or my employees with wages as their sole compensation.
-will do the work,and the structure is not intended of'ofered for sale(Sec.000.1,
Business and Professions Core:The Contractor's License Law does not apply to an 301 - ROUGH P204*ifMspections''
owner of property Who Wilds or improves thereon,and who docs such work himself
ofthrough his own employees.prow ided that suchimprovementsarenot imelwer or 302 - TUB & OR SHOWER.
brt<aa Rtr xw�'Ir.nbwxv<r.me remain -'--- o.orad wdnm ons - r . .. .... ......'__-_-_ '.— .--.-.-.-.- --.-_ -
geburdeovcnien aro 502 - FINAL PLUMBING ENERGY " •tL'r t
iompinion,the owncr�huildcr will have the burden of proving that he did not build or '
mprovemrpurpoaenfsale.). 506 - GAS TEST
_..._. -y or gw;' - - --507-----FINAL--PLUMBING.......--- ... -'-7-L !1__, - - - ... -
❑1,m r or the pmpeny,am exclusive tmcun th licensed conwetom m - b ! :.
comtme the project(Sec.700.1,Business and Professions Code:)no Contract.,,
License Law dues not up,ly to as°caner of p,.,.y who builds or improves thereon,
:. L ._and who.comects for-such projects with a.contmetor(s)licensed pursuant to Ne. _ _ ___
_ _ Comracwrs License Iaw.. F'INgLE
❑lam exempt under$tt. .B&P C for ibis reason I('.. - -t 1d'L
ownce Date ' NPR 0 3 2002
WORKER'S COMPENSATION DECLARATION
I hcrtby affirm under penalty of perjury ono of the following declarations:
❑ I have .ad will maintain a Cenificne of Cause., to sel6intare for Worker's BUILDING
Comp<mmion, as provided dor by Section 3700 of the Labor Code, for the
p<rri mta ice of the weak for which this permit m issued.
❑1 have and will maintain Wooker's Compensation Inamence,ss required by Section
3700 of the Labor Cale,for the performance of the work'for which this permit is
issued:My Worler's'Compensation lnmmnce carrier and Policy number are:
mor:
policCERTIFICATION OF EXEMPTION FROM WORKERS"if: � � �'•e '• I ,�a �.t.l t l.�t F1'3ti+..I f. '.4,x`,'1: '' 'I, 1
COMPENSATION INSURANCE '
.O .. --._.........._.. __—
(This sacnodneed net be completed film perms,s for one hundred dollars , I ,
(Simpler less.)
n I may rh t rh pert oma of the work for whichm pe 1 L.ueJ 1
shall t cm 1 /my\:y,' [ s toy)��co b c u th W°A rs
Cmmpe Ile aWi ef�.'.Jf .L11enM{� �✓ U )
. Apple M�(�f r
.NOTI E APPLICANT if she aking the Cenrficate or Exemption.you should I
nc2wne'si,njca tothe Faker's C, tpcnsaiioi,provisions ofthe Labe,Cole.You most
Q R forthwith comply with such provisions or this permit shall be deemed rtveka.
E-4
t •t CONSTRUCTION LENDING AGENCY -
1 he by ffrro to, h s onunecti leading.gen y r the performance t
> '1
W,> bribe work frh'ch the pidanit is issued'(Sc3097•Cis.C.)
;D,z Lenders Address,
V Q s
y,I codify that I have mad this application and state that the above information is
tat;E.. c'oden.l agree m comply verb.II city ad ,,.a,,.airman.,and stale laws misting
to building consminion,ana hereby iodation mpesenudves of this city to enter upon
the move-mentioned propmy for inspection purposes. - F
(W'e)agmen sox;mdemnify and keep harmlesi the Chi of Cuperiirio.gainst
F' h liabilities,judgments,costs and expenses which may in any way acerae ago nst said
U z City in co sequence of g t of this permiC
APPLIC 'ONDE A A DWI oh1PLYN'IYFfALCNONPOINT' Issued by: r Date
SOl C ULA - y'
Si time.IfI elmou �[grey/(by��d�in"g>ERIALSmit6ie�hSiMlc �NoL� Re-roofs
PP '•.
SURE
pp, aamasbraiceel Type of Roof - _ -
asdeandbytb Cre M 'p1Cod Chapter 912 no th H 1th dSarmy ;, .I c -.• - -' _ _-v,`I
code season 25s32(a) t �r •"t 1 f !' , "fi
: 17 Yes ` z a "'+ _ All roofs sliall,be inspected'prior_I any-roofing material being.installed.. , - _
.. Will the applicant f building occupant equipment devices which If a roof is installed without first obtaining an inspection;'I agree tdremove
emir-hazardous air contaminants as defined by the Bay Area Air Qat iy Management
Dutdet7 'I' all new materials for inspection. Applicant.understands and will comply with _
'� -
:;Y - all non-point source regulations. . -•ai.:•
1 ti vc rcad the brizardistis'mameabi requirements under Chapter 695 of the
California Health&Safety Cads.Seenimax 25505:25533 and 25534.1 umdcrstand that
f eb Id gdoes of officialyh
is t f th ayys ti h h must be m If p to Issue c of a Ced Bcata'of
/V\f
we
•' � •�L Signature of Applicant Date
w m,agenr' Date All roof coverings to be Class "W' or better
st. "r.'aa . : . 1 .-OFFICE - - _.- . . .. . .. .