01050007 (2) CITY O ;N
BUILDING No
UIPERMIT CONTRACTOR INFORMATION:
Bl11LDING ADURPSS: PI3RMI'1'NO
22$ D S d3/1lLYrf� Lo &6i�44 /`lG.
OWNER'S NAME. AITUCAI'I IN SUI{DAI F
Nt2uN 215 Ms k/rNenu+o� QC), Rn5 247
PHONE• SANI'ITRYNO. CONTROL No,
255 SwNs VALLey , 00 950
ICIYZ ARCIIITF.C'UENGINEEIt: BUILDING PERMITINFO
BLUG ' ELECT PLI MB MHCCH
no
_63!)335- u632 _I �I
S = LICVNSED COM'RACfOR'S DACLARArION
hereby ummt in,I am licensed under prnvianna of Charter a(commeneiny q� Job Description
°__� with Section9tXNoofOivisionJoftheBu,inessmWl'MiasionvC,dc.n.Wmyliccn„ �, yyT _ lstc—n-ren, P2ewe A-Leme#q-r.
< y= .s in full fmccende c! Lic.«4 �3B !
z e< I.iecnu laic _
a>� Dme �.i 3i.,�2pd1— Cenneetnr eILY1�N=
3 a✓ ARC111'1'IiCf'S DECLARNI'ION
t=9 oto I andcamaJ try plan"Imill M used on public rccnrJx
:amuail p O Licensed Profesxional
OWNERdBUILDER DFCLARA'1'ION
I hereby off nn.hal 1 am fl.r, font etc Connacmr',Liemue Low f.r the
_F z follua lnS moms.section 70315,Inosines,and I'm@,cion,Code,Any city or county
P x p which require,o remain to construct,alter,improve,demolish,or repair any amemre
a~m
prior or if, I¢)re,mbeldhe applicantfor such fe in file a signedmtenam
a-
I.;"he f : Ip t r 'hmon,ol he Cormi,lue,1 Law(Charter 1) S FL Floor Area Valuation
(cc b ,in Seen 91(Xp l la 3.0 the1{ : c d Pr f ,Code) q.
or that he ,exempt therefrom and the baas for the alleged exemption.Any variation
of Section)tU 1.5 by any applicant for a permit subjects the application a civil penalty
in but more man five hundred dollars o.9 X). I� AN N, 1 5 i Occupancy Type
❑I,as owner of the Pmpcny,or my enggoycn wont wage"mtheir sole comrcmntio 1. G� IS
will do the work,and the structure is not intended or offered for one(Sec.70,14,
Basincsv and Prufes,inn,Cede:Tne Comtncmr's License law does not apply to nitRequired Inspections
f.frot Prnpertyb send,ori im,des thctnd, and who tae,.wet wire riled f
or ttrr.ogh Floor,
ot......ho build, ,nava-thus sect nip who cas me nil Inando-1 a,
offered for.vale If,hats"cul the building or improvement i,%old within one year of
completion,the owner-builder will have the burden of Moving that be did not build or
sup far rfmp,,vvf,aIc.). 10,14�17
,.n,,mvf the at(See 9M4Bm , 1 li f. one C ad .1 n Contractor',
L e 1 does not ply t eof property he bio IJ improves thereon.O
n : fn b P i is int n t rO) d to : art to the - -
(lonlL. .1 liken,. .;+
a pt ad. s e. .I{R r`c�liarfn,i�..re;t,an
ovine_ Date 5Aza�.
IRKER'S COMPENSATION DECLARATION
I heresy uflirm under gnalty nl perjury enc of the lidlnwing dcdarationa:
❑ 1 have :red will mountain a Cenificme of Consent it) elf-insurefor Worker',
�Centpenvallon. a, provided liar by Station 1900 of .he Labor Cede, It, the
,,unarm bac of thio work for which this permit to issued.
❑1 have and will maintain Worker:Compcnunion Insurance.as required by Section
311X1 of the Labor Cols.for the performance of the work for which Chic rabbit is
waned.MY W..'ker'a C.....po,no,l n bt,urance aofv,;, I Policy number arc'.
Canter: Policy Na.:
CERTirbcNn0N 01;E\EMPTION FROM WORKERS'
COMPENSAI[ON INSURANCE '
(This%cation need not be completed if the permit is I'or one hundred dollar
(51Bid or less.) -
1...ily that L.the pe,fnn ranee of the work for which no permit i,i,wml.I
,holt bol enafay any pC,,on In:try nmnncr,u a, ,,Fort a,subject ra tba W.rkcrx'
Campenmtion laws of California.Uute
Applicant
NOTICE 10 APPLICAN I':If,after making this Ceniticum of Exemption,you should
Isoclinic able,,e.she Worker,C..npc...ininn pmvi,inn,"I the Lah..Code,you'if
Q O Ibthwim comply with such provision.,or this permit nKtIl be dccmcd«vnked,
Z
�. CONSTRUCTION LENDING a AGENCY, I homy anima that mere is a construction lending.t,oncr for she performance
.f the ,an lint which this final Ix „act[90 100I.Civ.C.) -
i°' Q I.cadfir,Name
= z I.cndcr's Address
V O�+ I ccnify that I have mad tbi,uppiwa tion and ante thm the alvrve Infatuation is
fsU Ir Cribbs..I once to cou.ply with.dl City unit county oral..;ncC,and,nme law',rehning
Q V to building carobaciion.and no anthnritc repreveli olds'city a+enter clam
she alone-nmmimed Netway far inspection parl ses.
t}. y (We)ugrecmxa c,unites and keep hurmlc,s she City of Catoctin..,must
m Ilanllidc,,int„ncn..v,cast:.sun xr Ind,n.ny In tray war airline:.goinst 1;611
V 7 City in cun,vy enanfinegD ns �)WIL,CO <—
APPLICA;T \DI'..TND. ADwILLCO,\1PLYWITH ALIN/O3NPOINT Issued by: Date
SOURCIi '.A It SNI �!
5igneu..e. tort. .ut/Contmue' Dann RC—roofs
IIato, UOUSMAfERIN.SDIt.DISCLOSURE -
WII me epCatied re M. huildCo,Chapter
r 9A 2.handle hazardous Safety Type of Roof
a1 detinet by the Capvnmo Manivip,�I Cole,Chapter 9,f 2 and the licalth and Safety
Code.SCcyon 25532p.y1 //
oyer iNa All roofs shall be-inspected prior to any rooting material being installed.
Will the applicant orfuture Wilding«cupamuse egnipmem',,devicc,wmeh If a roof is installed without first obtaining an inspection, I agree to remove
emit haz:udem,air contamimuntl an def ned by the Bay Area Air Quality Management
�D;xtrict'r all new materials for inspection. Applicant understands and will comply with
oyes "^ all non-point source regulations.
I read the rthe hazardous material,rcquiremens under Chapter 6.95 of the
C'aldonto Health K Snfny . da,Sections 25505,25533:md 25534.1 understand that
fmchniidingdne,not ion n IY l�wau mnuuL thwhi,my rexpa,ihditymnamymc
vocational the Imam al. which tont he all prior to kcvamnm al'a Ceolrcau,of
QCC.pa 5-01-01 Signature of Applicant Date
Ovines.fami„� Da,n - All roof coverings to be Class `B"or better
OFFICE