02010082 eJ BUILDINGUDPERTONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: APPLICATION SUB DATE
CAMDEN AVE
PHONE: SANITARY NO. CONTROL NO.
4083718000
t� ARCHITECDENGINEER: BUILDING PERMIT INFO
E w C BLDG ELECT PLUMB MECH
u
z m 2 LICENSED CONTRACTOR'S DECLARATION Job Description
D Z-C I hereby.Mon that l am licenxd under provisions of Chapter 9
so I- wiNSeaipornc]WO)ofDivisionJofNeBusin�yndProsrgGende.anamyhcenx NEW POOL ��{�� /�
z 6 Lia is in fuwLel . de Lic.x '/ S Y7�1,{'r�i LED
lc
)e 3 LL u � y9 cmdre<
0 0 O L an ARCHITECT'S DE AR
AT C
S 1 understand my plans shall be,used as public at`d. f� Dec C 2:3 2002
Y
w i p
cO Licensed Professional
$� OWNER-BUILDER DECLARATION �1, �p�
1 hereby OBiw thin 1 1. exempt from the Contractor's Co An,c taw for the BUILD
C 2 o following twin. ormit to
constru5.ct,
t,sines.and Professions h,or Any city someone LL
E o which us ii,m a permit re conswct,alter improve.demolish, fi repair any someone.
O O
.pooe dsissuance.rsuanttobe ft.pppomisiliwnt for such of the Cormanaer License
essignw Chapter
- (smartislicenfedpSectio tobeDivision
eBorne,andPoiaw.maCer9 a> Sq.Pt. FJoopQrea, , ` pp 1 Valuation
(commeticipg with Sution]IJ00)nf DivisionJof the business coil Professions Code) {;t.Rti r, 't{ y,i' � ,A
or thin he is exempt themfrom'and the basis for do,allepid eeemp600.Any violation 1 3'4'2'610'2�'. 0 O {
of Section 7031.5 by any applicant fur a permit subjects theapplicum m o civil penalty
;of not more than Eve hundred d9Eate(35uo). APN Number Occupancy Type
O1,as ref the property.ur my employees with wages as their sole compenmtion. 103 - UFER
owns
will do the work:and theumcture is no,intended'ocoffered'for sale'(Sec 7010; '- - '--'-iU4 _ HE=--- -; - -' -i ---.- - -- -' --'_-'--" '-- -_-"
Business and Profaswns Cade The Contractor's Licenx Ww des of apply to and Inspections'
owner of property Who Wild,or on,oves thromr and who does soon work himself 107 - POOL�BOND Id t
or through his own empmyees.provided that such improvements arc not intended m
-offered for mic If.ho th W lldiny 'in-P ement k a.[it within one year cf - - - -3 01 --—'ROUGH--PLUMB I NG
completion,rhe ownerWldc will have the hurvior of proving met he did not Wild car 304 - ROUGH ELECTRICAL
improve for Impose of sale.).
502- .---.FINAL_ PLUMBING.-ENERGY---.--.-- -.- ----- ---
-O 1,as awnensf the propenY am exclusively comforting with licensed contractors to
unsumerthep.j.t(Sec.]ou,Business adrroliner...CodcaThr,Commuros 503 - FINAL MECHANICAL .,ENERGY;
- License Law Juea not apply man owner of property who builds or improves thereon, GAS TEST II
L -eMnector,[Jecra foo such projects.with.a conwnor(x)licensed Pursuant m the. .._._..___.5-O.6__ __ -_._ . i..
Connector,l"tune See ', 510 - FINAL PLANNING
❑lam ezemp under Sec. � � � '.B'&PCfor this renin I1
511 - FINAL POOL
Owner"' WORKER'S COMPENSATION DECLARATION 516 - FINAL BUILDING
I hereby mTrm under penalty of pc jury,onc Tithe following declarations:
❑ I hove add will maintain o CsdM.m of Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the labor Code, for the
performhnce of the won for which this Ineomit is issued. ,
have and will nioinmin Worker's Compensarion Insurance,as required by Section
3700 Tire tabor Code:for the perfonnaiwe of the work for which this permit is
, _ its eJ'My11n, xC p,rxmmn Insurance carrier and Policy number arc _
'6140Va l e,.Policy No 1 f. 11 ! �r •_,�Oli.:. .':
C-RTIFICATIONOFEXEMPT NFROM R EA{
RS';' )..h.�tV ?v. .`y.,is. i l.
H'
COMPENSATION INSURANCE -
� bcJ net be clam Iemd'Rhe v
'i (Ih's srci non m p Pnmhisforonehundmadollvs _- I::i t 'i., V_aa Ifs..} !,v
(Sloo)urless.l ,
shall for employ any Person in any manner so as to become subject to the Workers'
Compensation Laws of Calit'orriia.Date'
-Applicant: -.-__ ._ __. _____ ... __. _.._--_..._. ._.. ._.__._._-__ . .._ -------
z
_ —
NOTICETOcto,th ANT:IL after making this Cr sur,of of Exemption.your mull `❑ -
xe bled t the No ke C pens Y p ns of th tab Code,you must
Q O forth hh mplY ith:uFh pr I......tIn,pc t an.][be d momidrevokcd.
CONSTRUCTION LENDINGAGENCY
7 I hereby affirm that the is a conswct on lending agency for the peAnimance
�,qof the wbfa for which dis pcomit is iswcd(Sec.3091.Civ.CJ _____.__....._..__....
Ise N - - u .. _._ ... . . _ _. _._....__ . -._
Lend Ad - -
. TZ -
V Q i rcnty that I base mad this application and slate that the Time information is
fn F clurion.l agree to comply with ail city and county ordinancesand slam laws rtlatin,
OU m IT filing mnsuutlon:and hereby vuthonce rcprcsenmtives of this city io coir upon
r� the above lay for imPsetiogpurpoxs.
(Wc)ig •to save; ei ify anJ keep hurnilas the City of Cupcnllio ayain.a
dp liabilities,jail cots.< andt panes which may in any way acme against said
f.) Z City m copse en the• in g ol'thi permit.
APPLICAN ERCTA IND W .L COMPLY WITH ALLNON:P01 Issuedb r Date
S URC F 'GUI.AT i • .L y'
ignau .ofA 'canUC m .Tr . .,; 'Da Re-roofs
_ AZAR US MATERIALS,DISCLOSURE It I
'
Willapplicant f need building p t.t tohundl h, d nsm i .Type of Roo£. - .._..._ -
is dcfnrd by!heCuPen no Mm c pet CTd CW pt 9 I?, d the HeaIN oiW S[ry i t,
Cod
Sent
_553]11 '' a / n it+t a r''('y 151
°; All roofs_stiall be .prior roofng,matena]b ing.installed.
i W IIJhe applicant or future Wilding r p tux equipment or devices whim If a roof is installed without first obtaining an inspection, I agree to remove
em ihada do n t i .deffed by the Bay A A Q I ty NI agement
District?
X�+T all new materials for inspection Applicant understands and will comply with
OY _ _ _. . ..__. __.
all non-point source regulations., I
1 time en rcqu renmtns under Chapter 6,95 of the
California Health& ,cry Code, a ons 25505.25333 and 23531.I understood that
if the builtlinBtlas nt cu a mwm,thm'n is my rcsponxibilinotify the - --
acuPam of the n¢w ust be t poior to issuance of,a"coC if cam of
Occupancy, - 4 Signature of Applicant Date
wner9r eT Tndee nt .D to All roof coverings to be Class "Bin or better _
..... .... . . . OFFICE--. -----