01030115 CITY-
I BUILDING ODVIONO
IIISNPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
7
OWNER'S NAME: APPLICATION SUB DATE _
ZONE: SANITARY NO. CONTROL NO.
O ZO ARCHITEC171 INGINEER: BUILDING PERMIT INFO
BLDG -ELECT PLUMB MECH
Z 1= CI CI I=
Fyi LICENSEDCONTRACTOR'S DECLARAHON.
OZ� Ihereny affirm mm lamlicensed unJe provi.+innz of Chapmr9fcammcncing Job Description
P:hu9 with Semon 7gxp of Division).!the Business mut m vsiuyfc c 111eee���uuar li<eme
4 y S,c i.+in full force and'eet. �fQ��^V
ma Liansecla+s J II « REROOF SHAKE TO COMPOSITION.
Po"i Dale _y ' _ c�mbm"(
j t'•y ARCHITECT'S DECL R ION
C a❑g 1 understand my plans shall be used aw public records '
T
ca Lis-ensal Rnfussionnl
E o ,fin I m-exemptIiR DECLARATION �rv�
v 1 neran.!firm the 11. ,Busies boards,hCnntracmr s License city
o for the
C Z Q fall gees: (Ser, h 70.11 5 Business do f:t s Code:sAny ry orcounty
m,mrc
I ❑ which "i permit- ..wet pi J.....0sh r Ys'tncmre
�u pr, P t hats 1 'he ppli ,t 11 nit tl g cluptc,9 -
mml 1 n dpam n 0 p viten rte t Communion, an IA onsCter9 Sy. F[. Floor Area - aluation
or that he is aing with Section om and t Division 3 of the le enr_as and Professions Code)
or that he i.exempt therefrom and the basis for the allege)exemption.Any violation '
of Section TO 1.5 by any applicant for a permit subjects the applicant to a civil penalty
oI not more twin E,,[I fined dollars($500), APN Number 'upon
❑1,as owner of hhe pmpny,or mY empbyces with wages as ded...le compensation,
will do the work,and the nmaure is.,it intended or nRered far sale(Sec.71114, r_r_ .
Business am r Prossians Code:The Contractor Lnenwe Law doe,no,apply to an Required Inspections
owner of property Who hdddk or nProves thereon,and who does ante,Woo;moself -
or through hi.,own employee..provided Inn ane.imptawemem.,are no,intended est
orrerm for sale.If.however the building or improvement I%-1d within one ye:u of 305 — FRAME .
completion,the owner-builder rill have the burden of proving that he did not build or 307 — INSULATION
approve for purls ere of awe.). a
1:11.as owner'If One Pmpcdy.an,exclu.+ivelycontracting with licensed comracimsm 601 — ROOF TEAR OFF
consume,the project(Sec.704a,Business and Professions Co k:)The Conwemrs 602 — ROOF PLYWOOD NAIL
License Law,does no,apply to an owner of property who builds or improves Ihemon,
and who contracts for such pmjects with a commcmrfs)licensed punnmhi ,o de,
C...Ilamors License Lawr 603 — ROOF BATTENS '
❑Iain axen,p„Inderse<. .BarPefor,lhi.ma+on 604 — ROOF IN—PROGRESS
Owner Date -
WORKER'S COMPENSATION DECLARATION -
1 hereby affca under penalty of Perjury one Of the following declarations: -
1 have and will maintain a Certificate of Consent ,o w1binsure for Worker's
nnpemation, m provided far by Section 37tH) of the Labor Cate, lin the
penounan<e of the work ks,which Phis panni,is issued
❑I have and will maintain Worker v Compensminn Insurance,as naltumd by Section
370()of the Labs Cale,for the pamm once of the work for which this permit is
sued My Workers Canyensatio,Insurance currier and Policy number at
Currier: Policy No.:
CEIG IFICATION OF ExEMPTION FROM WORKERS' '
COMPENSA'T'ION INSURANCE -
(This.+auion need no,he enmpleled If the Ihunnit is for nun hundeal dollars
($m10 or lew,l -
I army that or me perfnemana of the work rot which rob Penni,is issued,l -
shall not employ any person in any mannerist as ah biome subject,o the Wmonvs
Compensation Laws of CIJilornia.Duh,
Applicam ,
NOTICE TO APPLICANT:If.after taking this Certificate of liacmtaion,you should
become subject to the Workers Compensation provisions of the l.abs,r Coda you mus,
Q C) forthwith comply with such provisions or This Nion.shall be deemed revoked.
F 4 CONS9'RUM ION[.END]NO AGENCY
6a.71 hereby othrrimat mere is a construction lending agency for the Permiumnce
of the work for which this permit is issued(Se.3697,Civ,C.)
Isnder's Name
n
zLanders AJNs•.s ,
U0 lanifythat I have read this application and state that the move infom,ation is
E.. comen.I agree hu comply with all city and county ordinances and slat laws relating
r.7
to building con.aeration,and hereby authorize representatives nf,hi s city to enter upon
ley me above-mentioned 11.1,ly ror m.pcermn pnr,o+ .
F.. 6 (We)agree to save,indemnify and keep humadessme Chyof Cupenina against
y Linhilities,judgnemi coats and expenses which may in any way acme against said
APPLIC NTC NDERS'IANDS AND WILL COMPLY WITH ALL NO -POI T
SOL Rrc 3L norvs Issued by: Date �
_ .� o�i
. lel c o 0 1
ighlmre ornpph<anucommam Date Re-roofs
LIALARDOD$MATERIALS DISCLOSURE
and!
Will me a CtIpsm or mere ilml Co e,spam amre or handle har.,mnaa Safe,, Type of Roof
nn define)by Tho 32m)inn MuniciPa Code,Chapel 0.12 mA the fleullh and sute,y
Cale.Section 255321a)^
°Yes E)No
All roofs shall be inspected prior to any rooting material being installed.
Will tMappl'con ser futurehuilAingnhcupam use eynipmm�tnrAevicnwhich If a roof is installed without first obtaining an inspection, I agree to remove
emit huzanlans nlr cnmmnl..taws drained by the Bny Are Au Qualihy Managemm�,. .-
oi.mcl^ all new materials for inspection. Applicant understands and'will comply with
III Yes 0 N all non-poi [source reg tions. -
1 herr read the hnznrJnm mmcri.ls reyuiremenm under Chapter fi05 of the y-_-T/lN.
California Health&Satety Code.Sealons 25511.5,25533 and 25534,1 undeeeun d that /S /
if the building does not currently have a tenant.that it is my responsibility m notify the \� ^' .2� 0
Occupant of the myuirements which moat be met prior to issuance of a Cenifc''e of ll
sXcu n '/-II—/'
r , �l C G . 2/ r✓ Signature of Applicant Date
)caner of authorized agent Date All roof coverings to be Class"B" or better
OFFICE