01070124 (2) CITY OF
BUILDINGVIINPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
5903 SUTTON PARK PL NASRIN REZAI 01070124
D1VAW11V REZAI A0yjcyr1o�uSjIB001
PHONE: SANITARY
NO. CONTROL N0.
❑re i ARCHITECpENGINEER: BUILDING PERMIT INFO
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- BLDG ELECT PLUMB MECH
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mZ LICENSED CONT'RACTOR'S DECLARATION tion
Job Deseri
I hcmby ap
gzFouffirm that I am licensed under provisions of Chapter 9(commencing
ou withSereon7")ofDivismn3aflheBoomessandPromomr,Code.ndm neen,e INSTALL WINDOW & CABINET.
m E Is In full force and effect. y
rea License Class Lic.p
O D Date Contractor
3 n y ARCHITECT'S DECLARATION
t' O 4
j1 umlcraand my plans shall be used as public records
f� -
Licensed Professional
re
OWNER-BUILDER DECLARATION
='m 1 hereby Morn thio I am exempt from the Cnmrxmr'a License Law for the
? following reason.(Section 70315.Husiness and Pmfessions Calc:Any city ser cart, $20000
`z ee o which reyu ims n permit to construct.alter,improve,demulisb,or repair any etmrum
to 3- prior to its-issuance.also requires the pplicant for such Permit file a signed smtement -.---.-.. -
Oat he isI sedpursua t to Or p- softheContractodLc Law(Chapter 9 r ' Valuation
(comm s: th.Sect Talo) fD' ision3oftheBusines. dPcyr ic.,Code) j t,;,y`f•r3-fi_9 '6&�[•AEDai) ii`
.,,bar he is exempt themfrom and the basis for the alleged exemption.Any violation
-ofSection 703 L5 by any applicant for is Permit ubjects the applicant to a civil Penalty �n
of not muff than five hundred dollars S500). 5164P-NLIR$dT L BUILDIN Occupancy Type
°1,as owner of the progeny,or my employees with wages as their sale compensation.
will do the ware:and the structure is not intended or offered for sale(Sec.90x4, Ins
Business and Professions Code:The Contractor's License Low encs not appy Required echo to an Q P '
owner of proper,Who builds or improves thereon,and who does such work himself
or through his own employees.pmv)ded that such improverteau arc not intended or _ _ ioffered f I IL hos.ce the buildg or improvement is sold wMrn one year ofcompl t the ner-bu ke 'll ha a the Wien of proving drat he did nm build or
cmprof D Tale of I ). . L// _..
conas o e f Project
propcny I -vela contracting with Imensm contractors *x O - _ -construct the project(S c ]to a Business and property
who
Codey The improves
da mom. /,
and who
law does not apply roan owner of a cony who W lids a crop rsua themon.
`
and who rx Licome,L such projects with.a commnoriz)IicenxeJ pursuant m.the -
-�'
Contractor License bow.
°lamexem ttimer Sec. l '1B&&PP C fmthis reason •:" tlr" .
Owner / LPt J
WORKER'S PENSATION DECLARATION
I hereby)hereby affirro el percaft,at perjury one of the following declarations:
° 1 have and will maintain a Cenificam of Consent to self-insum for Worker's
Compensation, as provided far by Section POB of the Labor Calc, for the
peramortncc of the work for which this permit Is issued.
°1 have and will maintain Worker's Compensation Lnsumnce,ai required by Section
37M of the labor Code,for the performance of the work for which this permit is
_ issued.MY Worked Compensation Insurance carrier and Policy number am:
. I r.. Policy Nb.: .`•.; 11r, 'I';'f,`f)ia. ..v .I is•,'A.
P' ,CERTIFICATION OF EXEMPTION FROM WORKERS-1 c'
- -COMPENSATION INSURANCE , _....
i phis section dem not be campineA if the pemdt is for one hundred dollars j b •.1 7L
ISIDO)orlers.) -
certify that in the performance of the work for which this pemat is issued.1
shall not employ any person in any manner so as to became subject to the Wici
Compensation paws of California.Dae
.Applicant .. .. ... _. _
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should '
become subject m the Worker's Compensation provisions of the Latso Code,you must
Q Q fonbwith comply with such provisions or this permit shall be deemed revoked.
Zr .. .... .. .- _ _. .. .. _. _. L _ _. . ... ._ .. ..... _ _
CONSTRUCTION LENDING AGENCY
a'> I hkfor affirm that perm is
roved Sero Iciulmng agency fol the perfomucrce
ofnder's kfor which Nilpermit is issued Ser.}p99,Civ.C.1
A.
'-Lender's Name
DrZ Under Address' _
U 1 certify mat 1 have read ly n tmon end stem that the above i ion is
om.a.1 me io comply all cry and roomy ordinance,and ormrlaw,
relating
building construction,and
heby authorize repre,croarives ofm city to er upon
he
b t ds pcYf pwt F.'s"',
[}i 4 es,jg - t indemnifyIm e, i hat a the ad,wa f cc
pen against
./i liabilities,judgments, t d p scs which y seas, Y F asst sed _
U Z
City < y of the g t g f this permit,
APPLICANT UNDERSTANDS ANDS ANU WILL COMPLY WITH ALL NON-POINT /
SOl"C eREGULATIO' Issued by: Date
Signwurc of Applic'.ant/Convarn Dae Re-roofs
HA] U ,1ATER1ALS DISCLOSURE
.win the appncr or building occupan,orae ser handle ha:atdom;marmal Type of Roof- , . . . . . -. _ . ,.
as
difired by rbc CupeI in rt
case s M Code Ch p1e 9.12,and the Heullh and Safety r
r 255}z(a�, + '' Albroofs shall be ml •• t f
r t r s 1.` k.:.' .
°Y . .. `;pected.prior to roofing material being installed..... .._. .....
. \Modeappr,.marfuture bmldmgn«cicmiuse eyuiprnemardelile,whwh If a roof is installed without first obtaining an inspectio(i,'hagree4o remove
emmi h...n nus omr cmmoo ars as defined by the Bay Arca Air Quality M:ragemenr
Disrdcrr all new materials for inspection. Applicant understands_and will comply with
oyes ,.�Hn all non point source regulations:.
1 have read the haaaNirs m,len.1,rcquinomeivs coder Chapter 6,95 of the
California Health&Safcy Cud,.Sermon,25505:25SO and 25534.1 undemmrd but _
f Oc building does not cuoemly have i tenant.that'it is my responsibility to m llo)lie -
occupant of rhe requirements which must be Oct prior to Nsuence da Certilieme of
O«tipancy.
�. 2�— Signature of Applicant _ _. _ � Date
" owner or authemled agent,' All roof coverings to be Class "B" or better
_ . . .. '. . . . . . - . OFFICE-.. _ . . . .
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