02050137 CI BUILDIING DIVISION O PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19624 HOMESTEAD RD (BLDG2) BLACH CONSTRUCTION COMPANY 020501137
SUR
o � A'SAMARITAN UNITED METHODI 1650 LAFAYETTE ST APPLICATION
05/22A/2002
•�,
PHONE e SANITARY NO. CONTROL NO.
(408) 244-7100
O O ARCHITEC DENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i LICENSED CONTRACTOR'S DECLARATION
5 I hereb (firm that 1 am licenses under Job Description
mt.
yal provisions of ADD 220 SQ. FT. /REMODE
F:t with Scnian 7000 of DivisionJof the 1thessand professions C esMmyllcense
ag 4� is in fiat fo and e t
g�0 < Lic nu Lic.x FINALE®
y�3 LL D emen'
I untleG ICIA
ARCTE CLARA ION JAN 0 2003
O mantl my plans HIshall be a etl as Public records
oLicensed Professional
''e%• OWNER-BUILDER DECLARATION
I Ir '9_'1. I hereby a1Brm that I am exempt from the Contractor's License Law for the ��
Gfollowing mason.(Section 7031.5,Business and Professions Cade:Any city arcounty
wh ch I e a perm t to Construct.ehmq improve,demolish m raper any doneu.re
p toits issuance,al requires the applicant for such permit file asgned stammeni. - - --.- ..-._....,._...
Igath431'[cU(dPdssuanl'td lhF PmNsfonsofthe Contractors License law(Chapter9 _,f, .�-6'T31°810 0�<Wr®,�a,�i t,,,,...\� , Valuation
(c miycn�pa vri(h SmI1R TIXp) fDivision Juhhe Bmiumoapnd Professore Code) {,xj3 ,..l. L �d. A.i hc' 1,1. r: l vY,Dig
m shay he /ex rdpt thcrcflo�and the basis for the alleged etemirli e.Any violation
-of Section 7031.5-byany applicadt for o permit subjects Ne applicam m a civil pendty-
. .nrnobmorcmat,Evenanareaaogars(ssooj. 101AP-NNPIIWATION ;:'Lr<:.n1 1.11 Occupancy Type
El 1, of the propMy,mmyemployees with wages astheir sole Compensation, 102 - PIERS
-will do'the'worlgrshd the stricmu Is not Intended.1offeredfar1.Ie(see 7Bu: 103 - UFER Required Ins 'eCtiolls' `t'"i>'fl'
Bw
usmas- 1 Prdfesstons Code Lla
The Cimmuc m's toense w does not apply to an q p
owner of property Who builds or improves thereon,and who elms such work himself 104 - REBAR
or through his own empin ecs.provided thio such int ro cmcros.nil Imm�dend or _ __
Y.. p P_..__ _—
�corc�for she.uw however,the building or improvement n sold within none Weld of" ' -.._"'-"1'0 5-�- _ANCHOR BOLTS.-'---f.1 v;LIfi'. . .
completion,the uroo m builder will have the bathes of proving that he did not Wild m I
improve lira puryoae or emc.l. 106 - SEWER & WATER 1
Ol;.m_mvngdgf the n.am
_ r mexelua ""' --
nel cntmamnnseConstruct she Project(Se.704,1.Businesand Professions Code)lM Cotcr i —'-UNDERFLOOR-"PBIJMBINC+-----
License Law does nmapply[..am.erafproperty who Wildsorpmw
.thern. 203 - UNDERFLOOR MECHAN'ICAL!LI°:.T :rts : ca
im
_andwho contracts forsuch pmeme.wdh.e comractons)Imosed.pnrt to.tohs __._._.._-._2.0J._.--.._UNDERFLOOR-�-FRAME---
e License La s l e :fr �, UNDERFLOORG,IN$U�:ATI_O—NElIa exempt underSre fothmsn 05 _
o n -
1'1�o K"' "-6 4, "" ( - 301 - ROUGH PLUMBING
%;•`- _zv " 'WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby affirm under PCdyh.f adpjr,d�e aElhc to lawful;aetlemrioas:- 303 - ROUGH MECHANICAL
� I h v una'will' i o'C'mr t I Cnnum'io'self-ho,me for Worker's 304 - ROUGH ELECTRICAL
Compenamion, aa.provided-for by section-TIbYLof-the Labor Cade:-four he
pertaruin[ of IM1 work for which this permit Is issued.1, 305 - FRAME
❑1 h d ill die min Wmtas Compensation Insurance v req reE Gy,Sect on 306 - HOEDOWNS
3780 f thelabo'Code fo the Performance ofth wdrk f which this perm f is 307 INSULATION
T issue MyW rk ISC rapes inion In ra c arae e d P I y u be
T orr I rik.Ulii``BI(S`Grwi n'�Di'f 1)�.Ul�X3 .T}L�i 3 08 1$H'EIj;PROCK-
1 (,(lil=eR%7.FIenr1G oFE
[ON FRO.M�.,t...ER
INSURANCECOMPENSATION . ,, . .
- — - -3-10--. .INT�RPOR- LATH
Al ♦ . . �'t !)^.l 11 i.;iC' i•
ffhivseclonnecJnotbe
completed ifthe perms is for one hundred dollars 311 - SCRATCH COAT
i
i
151001 les 1 l
313'
Orn, 1'a,e'scrl 'mance f the w rktf h it l p mit iilx eJ
1hs 11 n 1 employ any,per nn In any ma at td hecom suq<a io thew(kers 501 - FINAL ELECTRi LALf't�ENERGY""l'
compo due w�"of c Ir Rtp _ •._ -.__ FINAL_PLUMB ING.---ENERGY-__.___._____._. _..-------
IN OTICETOAPPLICANTil;oftermaking this Certificate of Exemption;you should _ .70.tIVil
z bme4ubjectidlheWmoesCo pnsatinnPmvisionsolthe aWrCode,youmbs 503 FINAL MECHANICAli' ENERGY
00 fodhuhcomply-ithsuchVo ons or this Permit shall be deemed revoked 504 FINAL BUILDING ENERGY
[n r NICs5NSTRUCpDNLENDINcaceNO
- m 505 FINAL EL
ECTRICA-L
' 1aaffirm 506 GAS TESTa ; aith< rthywhrcthspermit •I ars 3097Civ.c)WQ Conder Maine
oarAadrcss 07----'-F
_—FINAL' PLUMBING
oz s, .a.!
:
I'•"
50 FINAL MECHANICAL
�r 1
'em"
fy thio I h a end this a.. t o and arm thm the.lire a mfmmm on s
kT+'� carter 1 g e lucomply uh all city and county,ordinances and tate laws relating
5 9 - INAL GRADE
O,p inWldmgconst don Jhembyouthonercpromman c rah etyt enter upon 5 0 - INAL ANN NG
ts7 th boe me i cd p peny for inspect p rposes
0.' IWelIgecie a ndemriifyandAePh Iraathecty rCpert o'ganay 5 - INAL RKS
Vi liabilities,judgments costs rad xpenu which may any y amg o t set d
t> Cly means fd g gohhs per t
APPLIC 1v i EA$ SANb WILL COMPLY WITH ALL ON'POINT vv
aVR RE ,entf .r.} , 1: le .� Z)' Issued bye Date
Sig sure. fAP1!li n omm4 r_;xt• v ,'s.,Date...,,'... Re-roofs .
u a HAZARDOUS MATERIALS DISCLOSURE f l
Will the opplcanlorfuture Wilding Ccepamstore or handle hiseardous matenil Typeof Roof___ .. .. _-�.. ---.- . ,- ..,�..�.........�_
ex defined by the Cpein M Icip ode Chapter9 12and the Health and Safety
Yn 2¢5320 , lire Y): ,, ( yjljditr s�srs
All roofs shall be inspected.pnor to_any roofing-material being installed..__
WII sh applicant orf rc bre Id ri cupent use, patent or de cos soh ch '` -
emnh x rill satrmntamnantsaz finCrib y the BayAreaArQualuyMamgetnemi If a roof is installed wittiout first obtaining an mspechom I agree to remove
Dtstn[t all materials for mspecnon Applicant understands and will comply with
ailit-4yes.-l- -.:l r N „ . Ij r - - L all ❑On-: =u'rc-e—r . ns illi'; rel Mts ave rcad,the h z , 'mmeIs 505, 5emrund C.1 t s that
In 1Sar lyClyhh.wICSin 25505titismnd255J4iuyto homy the4ignature
_( ing doessol curtemly ha eaten tthatntlmyrespanatbtlnyto nm Fy die
occ p if
f the reqs which mi t rte met pn r in vat ce of Certificate'of _
of A licant ate
nm ,
Oera .I iz<e o4, All roof coverings to be Class `B"or setter
._.---...OFFICE-. .. . ..__._
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