00100103 (2) CITYBUILDING
GUPERUNNO
IPERMIT CONTRACTOR INFORMATION:
❑UR.DINGAIllf�L�,}5468 VISTA KNOLL BLVD CAL—COAST REPIPING IM
"D001.00103
HWNbR'S NAMEAPPLICANON.II D I
LEE CYNTHIA F 1.371. TITAN WAY 3MI'15/2000
In %
E. SANITARY NO. CONTROL.NO:
(7.14) 578-5090
ITECnENG INF.HIL BUILDING PERN11'I'INFO
BLOC El ECT PLU.I MECII
LICENSED CONTRACTOR'S DECLARATION Job Description
1'enM1ynitirm ohm 1 am littnecd under rmvixions ofChnprcr 9lnnnmen<ing
eedari 71f1111ofllivw i3onhe Boora„nmH�' +fnot Code,anl�nr limnRF_—PIPE
ull trrtec nmlI��ff�1.I']aal Claes `` ..�O w Comm<mr n CHITCcr'S DECLARN'
t_u. S I an tand'orflar,,hull bar used as public t
J
to < Liccnred Prolevshoad
a%a x OWNER-BUILDER DECLARATION
m I hereby affirm that I m carpa the o firmCoradoo ',Laterite Law rot the
C?Q followingretnnn.(Sendn 17fDh5,llu.inoum
and l' raAir,ci
eion,CrM<:Aity or,mal,
x p which requires a permit arm construct,after,improve,demolish or Apar any annum
aim prior to its issuance.also requires the applicant for such peril in rile a signed statement
d3— that he islicen.sedpursuant tnthe prori..ism,of mmCnmmcmrsLicense Low Chapter 9 _ Sq. Ft. Floor Area valtl`tu��0
c `ing with Seciien 71N111)of Div' mB
3uftheu,inc,snnd Profo,siniis CW.)
or that hei,esumft thcmfmm and m<basis lit the alleged excin,A a.Any vlulmion
of Section 7011.5 by any applicant far a permit subject the afflicanr In a civil penalty
of net mom than five hundred dollar,6500). A PN Number Occupancy Type
32Er 13063. 00
❑I.t1s owner ul'ma property,m my nripinyec,wish wage,u,mcir note unnperv,mien.
,,It do he work,and the armure i,nm imunded nr offered liar talc IScc.7044,
Businc,i and Pred..iune Code:The Contractor's Liccme law docs not apply n,an - Re 'red II15 eCllonS
r of property Who Muld,or impmvc,linemen.and who does such work himself 202 — UNDEW"PL00 PLUMBING
,it hamgh W,,-.entployeet.provided that such improvement are not interceder
offered If bowuver,tat l j1di g nr intpro....car N toll within one y<ar of 301. — ROUGH PLUMBING
nnflve for purpose owe ad sale.). unta.e tat nnrden approving that neeid not nnim or 502 — FINAL PLUMBING ENERGY
impnrve dicii. n
01.as(woer of the pmprcny tan exclusively contracting with ficensed cannons,in 507 — .FINAL_ PLUMBING
n1wI ho that projec,(SCC.7044.Ilut ric,s IImI Profc„ions Cn fl)The C..nn
uanr's
Licen.ue Law does not apply to air owner of properly who nu ads or nation's lberema.
and who contracts for such project with a comranm(,1 licensed p iso ant to the
Onnwnor'n Liccme Luw.
❑I um c,,n,,ander Sec. ,13&PC for this res:
Owner Dae
wORKiiH'S CONtI'IiNSATION DECLARATION
I ereby affirm andm penaltynf perjury one of the following dcclarmiure:
❑ I have and will provided
n a Cby Section
m Conant m self-insure, for worker's
Crormanceo as work
foJ for by Section 3is X1 of the LaMe Code. for the
perlormun<c of the work for which this proril in ItucA. Q
❑1 hove and will maintain WmAer',Cnmpensatin i[it...i ec.,nr rcyuimd by Sect
3710 of the labor Code,for the performance of the work for which this permit is
itucd M NV kap',Compen on Iawmnce carrier and policy num O Z
Carrie � � 4 pelitvNn Non . / o� f2
CERHFlCA11HN 01:EKEMPHONFROM WORKERS'
COMPENSATION INSURANCE
o lik section nee I nor be comflered if the fennit i, to ane hundred dollars
01110)or las t,) -
I middy that in the pnformance of the work for which this permit is inmrl,I
,hall not employ any ,on in any manner sit at to become wbjcm to he Worker:
Cuntpcmminn Low,of Coliform'.,plum
Aprlicum '
NOTICE 10 APPLICAN'1'.R:alter making this Cenilicare of Iimmptinn,you should
become subjcn m the worker's Cnmpen,ation provisions of the Lather Codc.you must
C C) fnnhwim comply with such provision,or this permit shall be deemed minimal.
W CONS']RUCTION LENDING AC.HNCY
1 hereby affirm that there is a comwcholl lending agency for the peHimi ancc
of rhe work for which his permit is i.esued(Sim.3WO.Civ.C.)
L Q Lender's Nme ,
Q L Lender's Address
V C I certify that I port read his application and.state that he above information is
ti [� Correct.1 agree to Comply w ith an cep and comity ordinances and,tate paws marring .
C.7 m huilding conoracrion,and hereby amhorio,r<ryrwramise,of this city m emer tro.
FIbc ubnv Ionil pntpery for l n,,, opuses.y d. cc lnsava miscount, laurel rmlo,s.he Cityor Cnpeninommhor
h limbi rest judg marks cons s and a ich may in any way acerae against said r�
r At 'LICANT NDERSTAN A ' ILL COMPLY WI"TH ALL NONI'OINT Issued by:
/ Date
St U CHR iULAT10NS. �/�// 01 Issued
ureof,rpfiemm/Cnmmemr Re-roofs
n IIAZARDOUS NIATERIAI.S Il6CLOSURLE
Will desmplonat or rorare hourajng dccapunr store or handle haanlou,mamrial Type of Roof
;is delin,c]by the Cufadnn MamM,ail Cod.,Cbupmr 9.12,and me Hou1m end Safety
Code,Section 255321u17
oyes 0 N All roofs Shall be inspected prior to any roofing material being installed.
Will he upplieent of future bailual occupaat aw eyulrment tar Uttar,which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamahm,air nmbmlinal,toiletries]by the Hey Arco Air Quality Managcnem
District) all new materials for inspection. Applicant understands and will comply with
❑Ye, 0 N all non-point source regulations.
I hoeu rood the hazardous nutnsiolw rnlu l rcnent ander Chapter 695 of the
.ithlorma t&Safely Coxlc.Soni 25505.25511a 125914.1 unde,,wndmw
fmafei rugal ,n recommly ha ¢door.ram it t,my rmpamsibi lily it,noulyrhe
cuPar of the yuirameme wh' must be me prior m iswunce of a Certificate of
OC.opt 1Cy' Signature of Applicant Date
All roof coverings to be Class `B" or better
0 1 :m: at tat