08100007BUILDING DIVISION PERMIT
.R'S NAME: I
PERMIT L95UE DATE
!
PHONE;
A CONTROL NO.
(408) 898-7298
ARCNTTECnFNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB - MFLH
i LICENSED CONTRACTOR'S DECLARATION
Job Description
p
strum 1 hereby srm 1 am licensed under pmvidons of Chapter 9 (commencing
i with section7(slol) of Diviuon l of the Business and Prodessiom Code, and my licenses
infdLforeaaadeflc
DEMO 1 STORY RES DWELLING
License Clan Lk.•
-
Dam Comrmmr
ARCHTIECI'S DECLARATION
c I undemo nd mypans dl u shall he usPublic records
' Licensed Professional
S OWNER-BUTIDER DECLARATION
g 1 hereby affirm that 1 sat acmpt form the Contractors License Law for the
following reason (Section 70713, Business and Profusions Code: Any city of county
E which requires a Permit or construct. ser. Wpmw, demolish, or repair any sou sure
n prior to its issuance. also requires the applicant rorsuch Permit to file. signed statement
Ne Conuacmea U.. Law(CMpmr9
Sq. Ft. Floor Area
Valuation
Nat he s licensed pursuant to the provisions of
(eammena tug who Scctian 7000) of Division ) of the Buunessand Pmfnsinru CoEc) or
- that he is eaempt therefrom and the basis In, the alleged camption. My violauan of
84000
Section 7011.5 by arty appllunt for a permit subjects the applicant to • civil penalty of
APN Number
Occupancy Type
not mate Nan five hundred dollars (S5W).
37512006.00
0 1, u. of die Property, m my wpmyess with wages u dm'vsokeanpensulon,
will do than work. and the swaare is not intendod or offered for sale (Sec. 70M, Buuneu
Required Inspections
e. License Law. does rot apply se owner of
and Professions Cade: The CommerLicensem
PropatywW buildsmimper.thercagand who daessuchwotkhimselftar thmugh his
own employee, pmNded thatauch impmsensmru an not intended oroRrrtd fmaslc IL
however, the Wilding or impmwment scold within one Year of ee mpktian, the owner -
builder will now the burden of proving that he did out build Or improve for purgsse of
1, u owner of the property. sat to clualvcly contracting with ucc.VA conlose an to
consumer de project (Sec IMC. Business; and Prefesaions Code:) The Commitments U.
cense law docs not apply at an owner of Property who Wilds m improves memon, and
who contracts for such projects with a cenuaaoKA licensed pursuant In the Commuter's
Liana Law.
meaemp-uurnssyr See .B&PCferthsmsmn
Da
iIat If"`s1� te tI �
WORKER'S COMPENSATION DECLARATION
I hereby a04m under Penalty of Perjury ane of the fallowing declarations:
❑Ihaw andwill for by anon 37M of de, LabmCods,fumforerformsC of the section, r provided for mi Section n y700 0( Nc IaWr Inde, red Use Performance o(ale
edea for which this permit is issued
❑ I Nw end will munum Workers Compensation I., as matured by Section
37W of the latter Code, for me aformmee of the work for which Nis permit is issoes
My Workers Compensation Luumna artier and Policy number am:
Caner. Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
mos acaion need not becomphoed if the permit is forone hundred defrost (SIW)
or less)
1 certify Net in Ne prsformanco of me wah for Aic6 thio permit s issued. I slWl awn
employanyperamwtusymamermasl b iso 'xtmthe Warkcn'CmnPewdm
laws of Califomla. Due t
Appicant
NOTICE TO APPLICANT. If. after ma clog his certificate of Eacmpdaq you should
became subject to the Workers Compmition provisions of the labor Code you most
O O forthwith comply with such Provisions or Nu Permit shall be deemed waked.
'��--' CONSTRUCTION LENDING AGENCY
[-� .�., I Mseby alllrn Nat Nert s ec conuuuaian lending agenry for the prformancc of
CC the work for which this; Permit is issued (Sec. 7157, Or. C.)
WM A lenders Has:
r7 z Leaders Md.
U O 1 terrify Nat I have read Nis appliadan and sum One the saw information Is
44 F tortes. l agree to comply with all city and county aNiounces Nd soon Ian relating to
O U Wilding construction, and hereby aothonce repoescnuuwa of Ns city to enter upon the
[37 above-mentioned property fm inspection puryoies
6, (We) agree to saw, indemnify Nd keep humleas the City of Cular inn against
ti N liabilities,judgmens.eoguandespwa wbichmayinanywayam ,unstuid City
U z in consequence of the gontfnt of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGU TONS.
—Ll--/ 0, �zrl
Signucm of ApplicmUCan melur Dam
HAZARDOUS MATERIALS DISCLOSURE
Will dm ap,liant or factum W ildlog occupantslore orhandlc hsrardom material
rose! by doe Cupsmuo Munid ode. Chapter 9.12. and the Health and Safety
. Section 25552(a)1
❑Ya o
Will tin: applicant or future building occupant use equipment or dcviou which
emit ha sOlous air conomirwm as dcluad by the Bay Agra Air Quality Management
Dismal
❑ Y. o
1 haw real the hvaNuo materiasrequirementsunder Clopterd.95 afthe Califor-
alaHeslNASalayCadc Sccdam25505.25553and255M.Iandcrswd Natade building
does cot curmndy low a tenant. Nat it u my raponshilisy m notify me occow, of de
mqulremcnu which must be met prior m issuance of a Cenci of Occup
Issued
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class " ' or better