01060155 CITY OF G DON
PERTNO
UI PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10484 DEMPSTER AV ACTION PLUMBING AND ROOTER SER01060155
OWNER'S NAME: APPLICATION SUB DATE
TODD RUSSELL E AND MARGUERITE 1856 ALMADEN RD 06/27/2001
,PHONE: SANITARY NO. CONTROL NO.
4082962332
G eez0 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
m— BLDG ELECT PLUMB MECH
�a
LICENSED CONTRACTOR'S DECLARATION
o 8 N a 1 hereby affrm that 1 am licensed under provisions of Chapter 9(commencing Job Description
p„Fm with Stanton 7000l eroivirion 3 efd,e Boarrand Prareumnrexe,aadmy license - REPLACE W/H & W/SERVICE.
�x ad
isinfloe strut ellen. _ �Vss N �y�D
�o. License Lie.» 1NALf Y
°'O a U Date Contractor
3 u�, ARCHITECT'S DECLARATION
I understood my plans shall he used as Public records 11 C 20 01
i i oz Licensed Professional JUL 0 5 2001 ' J L
a. OWNER BUILDER DECLARATION
C xe I hereby affirm that I am exempt from the Contractor's L cense Lowf the BUILDING
5Sp
following .mason. Buse. andProf. bnsCodeAnyatya county BUILDING. $2300
which q npernt m construct all np lemnleh or ep 'ranya Lire
t t a q ''.II P'I' ' Il h ,to fl y d.'waxamL
thtfie sl”lCiansedpu tto the provisions fthe C t' i Licause La (Chapter9 'I OC d t Valuation
( mmccngwlthSeciln]000)ofoivtsnan3ormeeuanes,.mdProfessionsCoal f k 32�I�O g .:l�
or that he is eiempt the¢fmin and the basis far the alleged excoriation.Any vtoloupn -
nf Sechan 7031.5 by any o,hir m far a Pemdt srbieets me appic rt m a emu penalty
of not more than rive hundred donam($500). 106 APN gkftek & WATER 'Occupancy Type
°h as owner of the pmpcny,or my employees with wages as their sole compensation, _
will do'thewmic.and the structure is not intended or offered far sale(Sec.9144; � � p,
Business road Professions n Code:The Contractor's License Law does not apply an 301 — ROUGH P sections
owner '-
of property Who builds or improves thereon,and who does such work himself
or through his own employees,provided that such vemcnl menu an not intended or 302 - TUB & OR SHOWER
offered for..ale.ILwa
noev ,me building or m;prbvement is area within nor r to or - 5 0 2 - FINAL PLUMBING ENERGY
ompledon,the owner-huilder will have the burden of proving that he did not M1uild or
mProv`fnrpn"a`Cofsal`) 506 - GAS TEST
as owner of the progeny um exclusively conhaaing with licensed commaors to 507 - FINAL PLUMBING'
sun the project(See.7014,Business and Professions CiAr:)The Comourem's
License Low does not apply to an owner of,,.,Wy who builds or improves thereon,
[. [, and who,contracts for such Projectswhh.0 commctods)itmernd pursuant to.the
Comractari License Law. -
exempt untle 5'c. ALA
J ;e'&P gforthis mus
I
im
WORKER'SO MP a ATION DECLARATION
I hereby afrimt under penalty of perjury one of Ne following declarations:
1 hive and will maintain a'CIanificam of Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is iameE.(,,,,
❑1 have and will rh3innia Worker's Compensation Insu arm.as required by Section
3900 of the Labor Cale.for Ne perfoimand,of the work for which this permit is
sued.My Workers Comp malin.Insurance coon and Policy number arc:
C " Policy No.:
f
CERTIFICATION.OF EXEMPTION FROM WORKERS" - ( •-- ...,
:I COMPENSATION INSURANCE
tTh xectlan reed not be Mmple¢d if the permit i.for one huntlretl all...
:1 en fy th t n the pert - f h h tti 1' ... ., .• •. .. . ....
5 efthe link, p ismcdl , .i.. SI -
sl II n t roulpla,'nny 11,1.a in any roomer nus to heti e..bleu iu the Walkers
Compensm o n m Laws d Cal forma.Date, '
liblAPplica . „ .. ., .. ..
NOTICE TOAPPLICANT If fs mak'ngthaC ririnm df Exemption.you ghould v".
z be m bl nrtheW rk 'C pen' pr nsmthe LJhnr Code yon most
Z
O f nh th" ply w th ch p 'ons th' D< t shall he deemeJ revoked
Ff^ ' CONSTRUCTION LENDING AGENCY - --
I h rebs affirm that the-" a consort lend ng apiary for the performance s. t -
'Idowork fo hirb Ithis pearmatisissued(Sea 3097Cv C)' "
0. Q Lente Name
.. . .. ,. .._.. .. ._- _ .. . . _._. ..
=.Z k d Addrczv -
. V0 (. ..
�.- . I certify that 1 hove read this application and sate that the above information is
[..( comet:I agree ao comply with all city and county ordinances and whom taws relisting
to building consa.nion.and hereby authorize representatives of this city to enter upon
the above-mentioned property for insprruma surpous:
{{..a.t F•t IM )bSrceio rode nnlfy and ke ph I..i the CJy rC pedinouSaimt
Fw-W I b l t ) dg em .. a l expects h h y in any Y to.plana said 1
V ia
City m<o y core f the tmg of th m
ANT INDE t O LY WITH NO POINT
s I c u�aT � 6.2? L. / Issued by: ate
Sig�aµtre yr Apcart2artmmnr { ,. .Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W II th ppl c m (t buildi g accuPam stmt o.h dl naard..s tadm Type of Roof . . .. _..... ........_ . . .
as J f W by the Cuecr -M is til Cal Charter 9.12. d theHealth and Safety
Cal 'SectDr25532O t ,I "
It
❑Y All roofs.shall be inspected prionto any roofing material being installed-,
Will the applicamorfuture building me p, t use equipment ordevices,which If a roof is installed without first obtainingan ins ection;1-agree to remove
enth du.aarct s derndbytheBayArrAQaltyManagemen P g
n t t all new materials for inspection. Applicant understands and will comply.with
°Yeo - all non-point source regulations. • -
if have read the hazasdnus mute is Is requiveramis under Chapter 695 of the
ca foul Health&Safety Carel Sections 25505:25533 and 25534.1 understand thin
'sfill eb Idngdce not
t ", ve mnam mins mY po bditymnaiify the
occu t of the requ ns h ch m s t Prior t e of a'Id' cafe o! ,
(/�( -- / Signature of Applicant Date
D rip am���e( 5� All roof coverings to be Class "B" or better z. ._ _ ..
.. 1 OFFICE _