00080154 (4) CITY
OF Gut VISION o
IPERMIT CONTRACTOR INFORMATION:
BU1LDInc ADDRESS: 1.472 e; S'T77J—II IG RD Cb_.T) CX7LNIlRJJYff FiY)(:�1Yf�r .11 III NO. 00080154 1
OWNER'S NAME: 1:11"1 YC1NI:;fMCK RI31T l'1CA•'Ia. ..tits)
q ] UI"11:ffti'\tJIJ\ I'W APPUCAI'IONSl1U1?0
1oNE: {.f1:�/f_SI�IrJt!1
SALE IARY NO. l!1GS/ CONTROL NO.
G e z ARCHITECIIENOINEER: - BUILDING PERMIT INFO
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PLUG EhI;C'IPLUMB MECII
SNU C —1 1=1 L=1
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. = LICENSED CONTRACT'oR's DECLARATION - Job Description
O% p 1 hcrchy union that I am lama.,]nota,pin mo-of Chapw,9(1,1 all ng
tu�es'cafilo,'nofuiakat3m(leimotiLandPrnle,linn..a,ae.andI,,hcalle li'F:•7"II:1VF: E'il•'IAIGI_':Sy :Lhl.iifal—I_ 1/2 CD X F'9_YWDOI)
< y is in full force and effect. 7
= LicemeaaL, uc.4 FI_LT LT( IG-IT CLAY TILE
O0 i U Dan, Contractor9
ARCHI IiC'I"S DE LARATION
Ca O; 1 understood nry flint W used,,,chile itao d,
w�p'p Liccnwd 1'nhlc,aional
a.202,
OWNER man c'
a"I ,'t he DECLARATION
e�= 1 hmrehY,loon aha, 1. exempt&ori,hl,Carmelo Co :Any c law cfalls,
/
C? followinguire%a (Section comea Il.dtvr,end improve.
Wil Cale Any city or county
maM1 ts IK II erre Wc, Ile, p do I 'I Nh Y'I acre
prior to itsI e y thel I permitn is 'B ala l mem
moan dp .tion X 1 fn c a ,t 1 I on,Code)
-Sq. Ft. Floor Area Valuation
(e that he is a with Section ch,anof Domino is J nl be Bu,fico and pool Any% Cmle)
or that he i.exempt merefram and the basic for the allege)caonp,inm Any siolalinn
of Section 7031.5 by any applicant for a permit subjects the applicant u,a civil Penalty
of nor mem man five handled dollar,(550(y. APN Number Occupan e
❑L a owner of the p ople,or my em,hrirc,wish wages as Ihei,Laic corape—fiort.
will Jo the work.and the stmaure is not intended or offered for sale(Sec.9044. x
Business and Prnfcs6ms Code:The Contractor's License Law does not apply am an —KegUlre Inspections -
aiaol pro,o,Who I,ui al o nn ovc,mereon,and who dncL mch work hood(
or through his own employres.provided that such improeunwnts are not identical or ••
onered for sale,D.however.me building or improvement is,old windn one year o, :?(Y, .. FFd*H1_
completion,menwner-nuildcrwill have lhebudeli dpmaing that herid not buildor 307 — INSULATIONmpo.vc❑rpm I of vale.).
❑Lill owa,,fir me property,a,,,e.,Iu,iv,ly comm fir,w'Im licensed coaxal n (al')1. ROOF' TEn:Z OFT'
con%tme,the pnject(Sea.]Uu.Bu%inos and Professions Codec The Critical 60'f_' — R 01-*r FtYWOOD MIl_
License Law does not apply to an owner of property who hulld%or impnnas thereon.
an who contracts for Loch pmjcca with a nimmiam,)licensed pursuant eI,hl, 6f!13 - ROOF ],{f�'T'T'E]SLC>
Conuumor',Lwenw Law.
❑1 am exempt under gee .B is p C for this reason 604 -- ROCIF 114—PIRf,1C';RE03
Owner Date
WORKER'S C.OMPENSAI'ION DFCLARAl'ION
I hereby aRt under penalty of pe jury one of the tallowing deelemtionc.
J I have; I will ,nammin a Ceniticaae of Consent to¢Ir-insure far Worker',
Cn,npcmvalin a, pmvid,d for by Semon 99(X1 of mo Lubol Code. for the
performance of the work for which the,permit is issued.
❑1 have and will mnintnin WnrAcr',C•nmpenw,inn Insurance,a,required by Section
191X)III,he Labor Code.Iterthe pedorestect,or walk lar which this pernil is
aucd.My Wnrkcr',Cnmpemminn In,mance murder mrd Policy number nre.
Cartier. Policy No.:
CHRTIIICAI'ION OP FXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This,eiion need not W completed if the permit iL bit one hundred dollars
1511X11 fir less.)
1 c'm,ify that in the perfnntfanc,of die work for which thin pemli.h emuad.I
shall not employ any person in any manner u,as at[acnme subject In he Workers
Compensation Laos of California.Date
Applicant
NOTICE TO APPLICAN'll If,aE,,olaeng this C,toficuc o1'Iiecmp,ion,you should
Wm ean ,able,,Ili the ti Con,amsat I pmvi,ma,ol'the Lahnr0mv,you mit
Q O inch,ill,comply with such pmviaion'fir this,enol shall be deemed re,alvd.
Z
F CONSTRUE"1'ION LENDING AGENCY
Nanny naich moa therm iv n c9monS a Ic9Jing t.C.) for,hu perl'omwnoe
If work Iia wnich this Ixnnia i,isweJ(Sec.11Y)9,Civ.CI
yp Lander''Name
Q Z Lender's AJJnsa
U O I coils that 1 Nova mad this n mile....I viae nit fisc above emom,uteao i,
Lr. [.. comet.1 agree to comply with all city and county ordinances and,wta law,¢luting
Q (�
:a Wilding con,lmchon.:md hereby authorise¢pmLcnurves this city to enter upon
W he aMrvc-n,an,ioned property far iaapmaion purposcs.
LL (We)agrectosuve.Ioil e.nni1,told kip hurndc,s the Clly of Culxirtino again',
to Ieahiletics,judg ..eo.¢s and cape vel which may in any way.cane,pains,said -
O Z City in consequence of the granting of this petit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. Y'
Signature fir AMlicara Commaor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will tW applicant or future Wilding occupant More or handle hacvdnus matenal Type of Roof
rev dmtinual by the Cu pen hoe MLill icipal Codc.Chapter 9.12,mal the ncalah and Seely
Gale.Section 25532(u)l
❑Yes 0 N All rool's shall be inspected prior to any rooting material being installed.
Will the applic in,or mire nuudmg occupant use equipment fir devices which If a roof is installed without first obtaining an inspection, I agree to remove
,,it hmm�lm ;orI, 111i
ro r ...; oams IIs defil'd by the Bay Area Air Qumlly Manngcnunn
istna? all new materials for inspection. Applicant understands and will comply with
°Yea IDN" all non-point source regulations.
L
,read the Invminus,n inciul,requitenum„under Che,695 of,he
ealth k Su1'cty Code,S<c,'mn'15505,2553)and 25534.1 tnde,va IIhat
g docs nn,comm aly have a tenant.that it is my resryonibility to malty the
the requirements which must W met prim to issuance of a Certificate of
Signature of Applicant Date
man.�J agent Dam All root'coverings to be Class `B"or better
OFFICE