00050178 (2) P
PERTINOD1°1ti1°^ PERMIT CONTRACTOR INFORMATION:
79 SHELLY DR HOT WATER INC PERMIT NO.
ANTA JOHN L AND DIANE B 2531 GRACELAND AVE AIII.IGDON SUED9050 1:78
SANITARY NO. 1.
C i4 Z ARCHITF,C ENGINEER: BUILDING PERMIT INFO
kC (65fZf) 298-8494 BLDG ELECT PLUMB omen
tri
Gas
S y> I herchy utlirm LICENSED
h t Ilam liernµa un elr prop ons of Chapter 9(commencing Job Description
K"n is infamian9.ropdotubinhtnJonheBn,ter.:nmapmre„iaa,codam,dnmrprra.a
o P Lint fou fora and encct.
icctne clan Lic.p
5 LL G Dale Contractor
AHCllll'IiCI"S UIiCLANA'1'ION
CO unJers.;nmJ my plane,hull he owd as public record, /
� REPLACE WATER HLicensedPmlusional
i r LicensedS e OWNS in em ITER DECLARATION /
W m I hereby u(SectEATER
.int I nm em Bola roc Conon,Co License Law birth,f
C�< whichhollaorw acva fSmrst ,91131 5.I.dav,imp vedearnu h.- Any city nr if,
7F0 which rcyuion a perm..m c owdie alcor.improve,demolish,are.si'uny hucamm O
n 3 Print t .. m ekm q 1M �phc tf such permit rl g Jammmcm
thin fares licensed p.,.art thit ter,wort,of he Comeacnarsl . 1 (Chapter4 Sq. Ft. Floor Area Valuation
(,n g .In See ]aro) I M i,i l fid 9 . nes d P 1:fin,Code) 500
or that he is eseagm dIrmimm and the bus is lav the ullcgcd excngmon.Any vmlmion
of Scctinn 7031.5 by uny applicant for.pemtit Subject,the applicant m..,it penalty
of not mare roan five hundred dollars($500)0 APtl&6. 00 Occupancy Type
❑Lon olm,pn,p"lyo my saidoyces who wages us their Sam emn.coodion,
will do fir,work.and the swnarc sent ialca,ud ar oflered for role flee.9(44, Required Inspections
nn, me
ines,and Ihafessimw Case eon rit r%Liven Lane m ladoes not apply an y p
ryof pmpeny W ho huild,ur impro cs thereon,and who dons such work himself
oth,m,h h6 own employers.provided that Such Intprovnnems arc not Intended or
(,listed for wale.If.h rvevcn The build ng or impruvammrat is sold whnin one yem of
iantpmaan.tbeowner-hudderwdlhanerocmndenofprovingthat hedidaatbuild`mr 502 — FINAL PLUMBING ENERGY
mprove far Ifeliore of sale.).
0 1,!is owner of the property,itm codusikely contracting with licensed contract,,,In 506 — GAS TEST
...tate it,I...tjeed Ism.7044,Ba,htc,a end Pmfeseion.Cade:)The Connawnu, 507 — FINAL PLUMN I NG
Lice nse Law does net apply to an owner of prepeny who builh or improve,Ihcresn.
and who contract,for such pmjmts with a contmmortU licensed pursuant to the
Contractor's License Law,
C I ant exempt under Sec. .13&P C t'onhi,r.",a
Owner Date
WORKER'S COMPENSATION DECLARATION
I eamby adirnI undo penalty nl'perja,y one of the following declarations03 :
1 Save and will maintain.Certificate of Consent to self-insure for Worker's
,In Ktrsmion, as provided for by Section 3701 of the Labor Code, for the
performance of the work for which.his permit is issmd.
C I have and will maintain Worker',Compensation Insurance...required by Section
37W of.he labor Code,far the perrnnname of the work far which this permit is
,coed.My Workers Compensation Insurance varier and Policy number art:
Carrico Policy Nn.:
CERTIFICAr ION OIt li%ENYI ION FROM WORKERS'
COMPENSATION INSURANCE
(This taction need not be completed If the punnit is loot one hundred dollars
(S100)or cw.)
I certify that in the performance of the work for which this permit is issued.I
shall not employ any person in any manner so as to become suhjee to the Wmi ce,
Compensadnn laws of Cdlfornix.Dam
Applicant
NOTICE'r0 APPLICANT:If..err making dei,Certificate of Exemption,you should
hecome%object m the Workers Comlcnsmion pmvi.ion,of the Labor Cod,you must
O O forthwith comply with such prov:,inns or permit shall he deemed revoked.
FCONSrRUCI]ON LEN DING AGENCY
1 h
' ereby ani m that there is a cor,.mciion lending agency for the perfonmantt
fist of the work for which.his permit its issued(Sec.30iiP.Civ.C.)
L ❑ Lender',Name
= Z Ladcr's Address,
1 verify that l have mad this application and state that the above information is
li Ea correct.I agree to comply with all city and county ordinances and ame laws staling
to building construction,and hereby authirire relimscntativr.of this city to rmcrupmm
tee ahave....cutio-d pmper.y rar imprcnon puH,otts.
E„ 6 (We).greeit)save.indeinily and keep lanales.the City of Cuperinn against
Vi liabilitic,,judgrncno.cost,and expenses which may in any way acrmc against mid
�,7 Z City in consequence of the granting of this perm:[. q !
APPLICANT UNDERSTANDS AND WILL COM PLY WITH ALL NON-POINT Issued by: Date S U
SOURCI7 REGULATIONS. Y' , 'C
Signature of Applicant/Cnmmemr Date Re-roofs
I IAZ,ARDOUS MXITR1AI S DISCfOSORE
Will Lha applicant or hadn't btruding oc,a,pam,mm m handle ha,edmn mmcrial Type of Roof
ata dcntud by the Cupraiao Municipal Cade,Ch,ua 9.12,and the 14-1111.nd Satiety
Ctde.Section 25531od?
0 Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Wiul the appccnmortonal rhoHiingoccupant use ctlaipatent or Icviccvwhich If a roof is installed without first obtaining an inspection, 1 agree to remove
emit haeaidn I,ah rummninams ax Jclined by the Bey Are:,Air Quality Mms.gencen[
nntrie9 all new materials for inspection. Applicant understands and will comply with
ClYv, CNo all non-point source regulations.
I I hwo read the h"anjou,matcnal,re aircmen..m.lcr Chapter 695 of the
Cdl mens Health&Samy Calc,Section,25505,25533 and 25531 1 mdecuunJ Jr.,
r if the building does not currently have a[count.that it is my mv,mvihilitY to notify the
cupant or the requirements which mus[be met prior to issuance of a Cenificam of
occupancy. Signature of Applicant Date
Ow net or au.hadsed agent Dam All roof coverings to be Class"B" or better
OFFICE