02020084 (2) CITY OF DI
P SION
BUILDING PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESSPERMIT NO.
OWNER'S NAME: APPLICATION SUB DATE
CARL BUCK 1712 STONE AVE 02/22/2002
PHONE: SANITARY NO. CONTROL NO.
(408) 293-4717
❑ ARCHITEC(ENGINEER: BUILDING PERMIT INFO
w O BLDG ELECT PLUMB MECH
a Z =.
y 2 LICENSED CONTRACTOR'S DECLARATION Job Description
5 z-❑ I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
ml:m with Section 7000)ofDivisinn3ofthe Buonewand Prnlession,Code.and myIcinm INSTALL CENTRAL SYSTEM A/C.
¢-E, Lien class H forceppsy �� � �/ 80000 BTU FRUNACE & 36000 BTU A/C &
5 3 c O Liccnu class- -1L Lic.x
Da¢ ' - - Comrannr
L01
ARCHITECT'SDECLARATION 10 DUCTS INSTALLED.
I undersand my plans shall be used as public records
yz ce
u p 0 Licensed Professional
OWNER-BUILDER DECLARATION
=so I hereby arm that I no exempt from the Contractor's License Law Italia
C?< following reason(Section 7031.5.Boniness and Prafcssions Code:Any city or count,
E'^❑ which mqulra a Permit to ransomer,alter,improve,demolish,or repair my struaum
ce6
3,o piton t unto.also aq 'rcs he applicant forsuchpesmit mfileasgiuN suamem. - - ------ - --
that be is lochtcdpnuonu0ibe poyi os M the Contractors License law chade,9 s , Sq•,Ft: Floor Afea -5 'a Valuation
(tom c g ,'N SecJon 70)0)ofDivision 3 of he Business end Professions Code) t.ONTI>'1s,. 'a Q•iit :A\ „351s P.q a,yQ i1\ $6000
or that he A enempt therefrom mad the bass for the alleged.Atialabn Any violation
of Section 7031;5 byvoy opplimnt far a paten,subjects the applicm,m a civil five hundred dollars 1s5W). APN Number i pcmdl,- r
;of not mare than .•• Occupancy Type
01,as owner of he property,or my employees with wages as their sole compensation, 37508036 . 00
will do the orR7and ihe'nmmure is not intended or'olfered far sale(Sec.-II44;- - - - - -
fBusincss and Professions Code:The Contractor',License taw does not apply to m p, lons
.waterofpmpenyWho Wild,or improve,hereon.mad w h.d.,such w.rkhimselr 303 - ROUGH ME;gg�I.: laeCt
or through his awn employees p 'd d that himprovements t' i e d ._ 3 0 4 --- -ROUGH--ELECTRI CAL-- - - - - '
plf red forale If
how
the building_ i cis lei int l e y f
<ompletonheownerwla rah ethebrde fp gthtnaa ,Wild o
prove for purpose of e) 505 FINAL ELECTRICAL
508. - FINAL.-MECHANICA
__
01 aown<cof he prapcny m exclusive], n tre 8 with l sed moo t
tt
I'
omationan
project ) tos ..
1. Lice L does not a t neo cf n hit bis ld. mon
and whtots Lcettset�Ppy7M4)B .cimmfes n) Cone o t .
tyle . ------- _. __... -._ .._. _...._ ..
cia
and who contracts.for.s cit roec¢with a co sracsor(s licensed tot
01 exempt ndersc �, ,B&PCT this rcawn I
.. /Own r Date ^
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
p I have and will'mdzinum a Ceni0cme cf Consent to selhinnurc for Worker's
Compensation, as provided for by Section 3000 of the Labor Code, for the
•performance of Ne work for which this permit is issued..
01 have and will dome nio work'er's Compedsatim Ihsmance,-es required by Section
- 3700 of the Labor Code,for One performance of the work for which this Permit is
ssued.My Worker's Compensation Insurance-cancer and Policy number are,'
¢ ( IAF'=/Jr ....._ _. _ .._ .
Cirri. Polity No `I'� l•rl / f: .�. r� jt !e r--s•i i a y. a.lil'.f
�FEKEMPfIDN FROM W RKER L. ; se. C l ,.
R
'COMPENSATION INSURANCE';, _ �, .. _ _ ......... _..
"•(Inn sen bit need not be rompletact of the permit is for one hundred dollars L.
(51 W I or Icsn.7
' I.certify that in the performance of the work for which this permit is issued,I --- -
shhll not employ any person in any manner so of to become subject to the Workers
Compensation lawk of Califomia.Date'
Appl coni
•NOTICE TO APPLICANT If after making thCenifcate ofExemption,you should '
Waco' -bl,cu th Woke s C n pc . t P' sof L bo Cod,you mon
Z0 loon h ply lh such provisions or thisPermit h shall deemed ked. 1
s••n . ?CONSTRUCTION LENDING AGENCY
a ; I h Oeby 6 that there construction lending agency for the performance
W..r of the work fa,which his permit is issued(See.3097,Civ.C
Q -Lender's Name..._r. _. ....�..."___...,,....___.-.._:_.:....>>.:.. ... ... ...__.-.. - _-.. ... . ._._.
Z Lcnaer'sAdtlress
1<eni(y that 1 have read this application and state that he above information is
Wee... `c'orieci.t agree io comply,with all city and county ordinances and state laws relating
Q V Dobuildingconrmnion.andhercbyauhonu represenmdves of this city to enter upon
t:fry the abo(We)!0oned pmperty fmofy and kit purposes.,
.�, st
IZ) es,j)dgmeassave,andepenndk hiep hamyiniless lanyhe wayity acTe agripm said
h Citj Inco sequence costs end expenses which may in any way active agaj. said Si V.Z City inconsequence R T granting of itis L c os..', v
APPLICANT UNDERSTANDS AND WILL CObIPLY'WITN ALCN -PO NT Issued Date
5O{IRc'A"REG ,\T}�'JS. ';t,': J' /7.J//�/ y
mindilhir
��-I ,w)n he a GAZA fDOU Moate RIA ant stow m nanme ria nm �- Re
HAZARDOUS
CM S t n 25S21d RIALS DISCLOSURE
wndS .at Type of Roof
as d f e i N C pens p Municipal Code.Chapter 9.12.end the Health and Safety s •. g
i HAZARDOUS MA
PD
t� ', SP ! - J`1 l I 1 "s�[mt
lit it � 1
oY - 1 N t `;?zee, I 1 All roofs-shall be inspected prior[o_any roofing material being installed,. ,
w'um .,pIicanao future building p i useequpment or devices which If a roof is installed without first obtaining an inspection,.1 agree to remove
emit ha=arLousat shat ams aa defined by the Bdy'AraxAr Quality Management
District? ,o•i. - all new materials all non-point source rinspection. Applicant understands and will comply with
0Y f ..;
"I ha o mad he hamrd0 s,matenals rtquiremem,under Chapter 6,95 of the
California Health'&Safety Code;Sections 25505,25533 and 25534.1 understand that _ _ _ _
if the building does not currently have a tenant,that it is myrtsp,midalirymn.ory he "'" "-'-" - ,.
deco' not to Wheat of a Certificate of
.p t f to requirements is hon must be t p
!. she cY - ,.
a � , Signature of Applicant__ . -,. _- .. . Date
.r
owne p m d=pa ag t - ' - ane All roof coverings to be Class "B"or better
,.. .
- OFFICE . _ . . ._ .. _. .