04120151CITY OF GtiPERTINU COV, ��:T(��
BL'ILDENGD1V1sION p
PERMITN
�j41201�1
nUILDINGADDRESS. IPPR CONSTRUCTION INC
pERMIT Lc&M DATIs
OWNER'S H AMti'i
RK PEOPER11
SANITARY Hf). CONTRtH NO.
PtIONEc
4? 4 BUILDING PERMR INFO
ARCH r1`5CT/fiN0lNM.
BLOC PLUMS MRCH
J 8 YO LICBN58it G()NTRACTOR's DECLARATION
Job Description
G 1 ticmby sirsim that I sin timpsod uadar provisions of Chaplet 9 (asmmencclnj
? y j wilh gs coon T6tl6j of Dlvl d a M ttx Bussnosa std Nvfes3nttt* Ct end my iluc tic is i bis �i sr tT P GRAD E C OLUM Su / .S LAB
'4 < F. in full (once and Offal
z t.4cenlc Gams _ �^ �- ---- Lis. s
Contractor _
^ qqq^ Dam
W ARCHrri GTS DECLARATION
1 urAC,1 ltd my plana *hail be used as public: MCrirda
Licc'nsra Pnifawnnsl
OWNER -BUILDER DECLARATION
I herahy afF3rm that I am exempt from the Cunuactm's License Law for tb9
o fWbwung reason. (Section 1?13I.5, Business and WMc stuns Code: Any cry Of county
n
which rcvl'Mres a permit to annsuttn, alter improv4, demultsh�nkmpet ytwumanl
y.r
i"ttLtcc, also rovini s the applicant (or such R
S t, F1twr.Ar `%5 uatton
prior so its
Line provisions the conuactui s Licenfc taw tChapmr 4
G that he is lice rimed pursuant to thn tis
lulltlnf of alio.he 4 cts cLenn w,ProfessionsAmAltwam)0Of
. (COM mMt9ng with Section1000)and fa tine alleged ercmptlon, y
occupancy T1
tCA he
r¢ that ix b maampt Ihelefront and the basin
for a wbjc,0 the apptktant a A civti p*nahy of
3 (�} pe
Stellar, 1031.5 by any sppksnt ocimk
not more Mat 6tro hnnihtd donors Fs1<10�
0 I, asOwnerat the Property. or my employees wkh wages &a iheit sole compensallnn
or Offsted par mals (Ste TOM. BuslOess
Required inspections
do the wail and Ne air cion, is not toended
OW ProfesLors Coda: Tux ContraiMI'S 1.109014 Law docs 001 apply to an Owner of
who does such wort himself Or thmogh his
Property who Wilds or Irnptoves theraan, sod
own txnployaes, provided that Mich Improvements are am imandW a offered (orale, If,
.
how,ever,ihebultdingorimprovsmNU issold Within oneyawefcompkiloo.dutowner
balkier +vitt ism the burden of proving lhti he $id not build of imPrOw for I of
uk,).
L] f, as owner of the prOpeny, am esaiwlve5y contracting with licensed conu&AOra to
Professions Ciode.) The Coeuaetors L•
construct tux pm)cet Mac. 110.. Bull RM and
sNa4 Low does W, APPLY la an awael *( property who bands a ttopro t&G� Cw �tt�r a
Ik*netd um
Who co0uartt fw mucin "Cls with n eattrt atnr(i) purl
Licerac Law. Bir PC for this maws
Q t atm exempt order sec.
Rale
owner Dole
ATION
I heaby aflsrm natkr petuigY of Perjury "" t#f Utt lollowittg dectaratio M
[] lhaotWwill mainuinaC"ticaAofConsemte4dr-wintrot Worker'sm-
Section 37M Of the labor CWa. for the pe*f
&"too,
as provided fax by
work for wbica this Permit U issiaed
0 t have sad will maOW4 R'~s Campeo,,a • mita t Section
of aha v wk for �+"�4 �s laded.
3700 0(du label C0&. Ax the performs m
My wcrkeft Componraucto Insurance carrier oral Polley number sre:
Corset:�-,-. Poi cy No.._
,-'EMF aM. Dl` ajJ PTtON M)M W (AKMV
COMPWSATION INSURANCE
:.
mw section nod moi be compiew if the permit is rot aaa ba wind tw (;160)
or utas.)
1 cain(y dAt N the p4rlb"Aw or u:c wwk fon wtcch this i4re"t Is ka.+ied,1 shall nal
in any manner in as to 119cwno srsMaf to the Worttri compemNNOn
waptoy any person
LAws of CA11101WC Date
NpTyL'fi Tel XPPLICANT: It. afw making IAia C9Nficate OfI3ztKnption, you t!u>vki
of the I.aY-tar Cade; you must
bovoms subject to rho Wakes Cctnperwliat Provlsom
Z forthwith comply with web grmntitotts ate this permit awl he doom d smvoknd•
Z.. CDNS"M1jC"QN I.BNDINO ENCY of
shat AGENCY
there IS a ttrnsund) uc"M le4geexy. fa the perjtaiil
*Matt
1 hotabr *Ma
p r`'r' rile wok fur which dun pvmit is issued (SCI. 304T. Clv. C.)
�t Londe, Address
` 1 certify coil hi have aid us.s appticatiom and tum that ate shove inf nntatniHt to
of this city to carat uponshove
t V Cw cOrr¢a. I sgrx m svaply with all City and copnty odinar 4 MW state laws rtiadmil toLRewroofs
F� busltini eamstrctton, tori bercmy ranh4.'ire toprmaaauen9&
Woucnad pupertY for tm+icati'r t am.(We) sErce to sort, rndcaAffy wd keep htrralass kik City of Gvpctt
whlchattyinmay wayatizir9 aga>tit said City
tCoats and aaPcntes
- liatC
in ti of the graining of that p9tmt6
NT
AND WILL COMPLY WrTHAU..NON-POINT„SOURCE
APMt UNDERSTANDS
RF GUL ATIONS,
St>swmeturc of Appireomu'Cuntr"tOt S
KAZARDOUS MATERIALS DISCt O
Type `ftp of Roof
Wits dt9 sppl:vadN or future bvildsns occupant Attic of bandit harardow MIK�tial
as tieflotd by UK C4, 01ri o Municipal Cod+:, Cluyiter 4.12. fad she HWIA NW Safety
{
� All roofs shall be itls}s�ied prior to tiny roofing material being installed,
Ctta9. � �ss��{a3, � �
If a roof is installed without first obtaining an inspection, I agree to femvwr
4ya pine°t
Wit, ft applicant of (toors Iwkdtng occuWl Use to devices Which
by tine nay Area Air Quality Maaseco'cm
all new materials for IRspcctlon.
Mit haratrpms air e00nn.namu ap itonned
Dirt: tett
0 Yea C1 No
1 hw. m al Cite narardiws nilmiAit "immoins whkt Chapter 6.45 of die Califot•
afas,!(,FuiWtmg
tine
_
_ u � � ....e-
axWaM&SafctyC0*,Sc_ums255tf3.25533uu125�.44.luri&rat
Ja9s nrtt cmrenily f ttva. a ImML diet it is my taPonnhilny w O"ely iM acupaitt flf
leriav�tiit9ofaCtNikM4ofOcet soy
T_�
Signature ofApplicant Date
ee�vtreratntMwhenmsnb mut briar
All roof coverings to be Class "Bi' or better
gwn0r un aulhart7rd erg..^ni
,-.