00120056 crrUtNoFcuPF.RTNNo PERMIT CONTRACTOR INFORMATION:
BUILDING 1'0948
PERMITNo, c
c '�4fi SHELLY DR 00J.c0t�..)E
OWNER'S NAME: APPLICATIO SLI
JACKSON WT.I_LIAM D AND JR QUEI_T �,—/bT6/c^.000
1ONH: SANITARY NO. CONTROL NO.
O ac2 ARCIEI I'LGTfliNGINFIi R: BUILDING PFRMIT INFO
O O BI.DG ELEGT I'LUMB MECII
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i7yy LICdNMID a fieviBd male,SDRC...of CION Job Description
i^O 1 bcrcby allinn tial I tan loaned sends Wovisiom of Chapter 9lcammmomne .
FHF-W is ih Scaiorce an of In,,
lal'the dminesa and l'ndcasion.CWe.and my license
a, in bill fuse and cfl'cch.
z 6 asc Cats Lie,a
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Damn G,mmnor SHAKE TO OSB
ARC ba uw I'Ibe av pc ARAIBON /
I undc'ni troy .
hey phis ll be uuN m rihc records
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treat a o O Licensed Pmlissimnal
OWNER-IEUILDER DECLARATION
1 hereby mar rota I tan csemp,nm.o the G...no,r',ldecnce 1,w fir Inc /�
C Z a following ream. Need c 7031.5.Business nnJ YrnlFssions Gale:Any dry nr count'
x C which ayuires a perms m construct.alter.improve.demolish.or apait any structure
ce
do prort t I. y hi ppl' tf II a II h Ltt tart
c. teal lic,noadP ,mra to the po,,i%c f fla,Conaracho,1-1c,ow Low chr,am9 Sq. Ft. Floor Area Valuation O
re,mormovin, 'thSection 70(M)of Dl ulB JY f.- Code)
or that he is exempt therelrum end the basis for uncollected exemption Any violation V
of Seen 7031.5 by any npphcant turn permit eud,,E,the aprhlror m a civil penalty
of not ichor,man rive hundred dollars S5fdl. APN Number Occupancy' yIpe
❑I,as owner a1 the property,or cry employees with wage,as their sole compensation,
will Jo the wail,,rad the suuctam is nal intended or otfned lot wlr(Sec.71144, - 3!5191,51210t.
Business and Prole Ovir s Code: am Comracmr.Lknrec Law'die,not apply ti a. Required Inspections
or of pri Who build%or impmvcs thcreun,and who does such work himvelf
r Ito nugh h'm own crnpiny<cs.provided thin such haprove nen].,arc no,iforded lir
offered tar ale.It.het me I,niming' mvro eat "old wi oor o e Yee of ,X05 — FRAME
,omplcdon.tee owner lwiir,dcr wAI nave me ndmr of Proal.,chat he did art build or 307 — INSULATION
improve for par d"t,of sale.).
❑I,an owner of the pmpetty am exel-ively contracting with licensed comm<tm.m 601 — ROOF TEAR OFF
construct the pmjea(sec.7 s.Business and Pmfo,sions Code:)The Cmdrai 602 — ROOF PLYWOOD NA I I_
Licenw Law does not apply h,an owner of propety who builds or itnpmve,meteor.
and who unnnuas fill Inch prd1111 suint a mntmctor(s)liccnacd porvad rte the Eh03 — ROOF BATTENS
C' I, i ,s License Ire.
in elve der Sec. It M P C lot this mason604 — ROOF IN—PROGRESS
Owncr Date
ORKHR'S COMPGNSAII N DECLARATION
Ihere alf or under pcnu by of par'mry one of the followi ng declamacon,,
J 1 have and will maintain a Cel creta of Corwin to self-insure for Worker's
Compensation, is pmvlded For by Section 371X1 of the I.abur Cute, lin he
perl'nrmanee of the work for which,his pctmit is i.cncd.
❑1 have and will maintain Worker's Compennaien Insurance,as required by Section
3710 1 the L:mor Cn le,for the Ferri,nnnnac of the work for which Itis perm]is
issued,bay Wodcr's C1ulyy'n,aynl I arc canner and Policy manlier arc
Cnrriel: / /�(-`y I'alicy Nu.:
CEIi'rEBCA'I ION UP pxrMITION FROM WORKIiRS' ,
COMPHNSATION INSl1RANCF
(Tats wain.noeA not bo completed if the Fermi,is for ane hundred dollars
($)1X11 lir Ims)
I crafty that in the'rhommnec of the a!'work for which this peons h is issued,,I
,hill t pi Y Y I toy /et h�� a h Wurkcrs
Co n11C :I I t I )t d' JYJ
N(YI ICI tTOAIII rf,arf�~d. gilt car heofL pt > mould
M.enhn
eshbjeaotM1 kst qe ar hl' , < %h I:h Cd te
you st
Q O forthwith comply with such povidone or his permit snarl bo deemed rooked.
Z
zE CONSTRUCT[ON a;LADING AGENCY
> I h1,r uflimt that there is a cn,ulr(Sec. h'lullog agency im the pnfnnnmmc
of Is end far Ir It chis rc.u� ed(Sec.11F)].Civ.C.)
L Q IanJcr'I Name {� �J
� z Irnderl nAJr'can �T
U 0 1 vertHy that l have mad this application and state that the above information is
I,. F.o coram.I agree to comply with all city and county ordinances and cmc laws relating
Q (, Io handingeanaaction.and hereby amhmi/e repr,worlike,ol thin city to enter upon
} R: the abovotnentioned pro,.,Iia inspection purprhnn.
ti95c. (We)agree active,indemnify and Acer harmless me City of C.,rc against
01 liabilities judgmmuts,co<I.and expenses which may is any way accrue against said -
U Z City is cmuequer al the graaling of this permit. �y q�
APPLE UND.RSTANOSAND WILL COMPLY WITH ALL NON-POINT IssUedb Dale /2^ d1/9/
soul ,RE(']I TIONS `rte , y'
Mgnmmmi <ahh ,a- 5r'G Da,= Re-roofs
HA]SRDOUS MATERIALS DISCLOSURE
Will licapplicant or Entire balkhric(werrial store,or handle haVool—ormial Type of Roof
s defnal by the Cnrpeiioa Municipal Code.Ch.,,,,,1.12.and lie etc:dm and Safety
Code.Senior 25532(3)! /
✓
0 Yes " All roofs shall be inspected prior to any roofing material being installed.
Will the appgcma ormte mhdhbn,o,m,mo sur npripnmnt or devi<cs wlach If a roof is installed without first obtaining an inspection, 1 agree to remove
mit hmmNous air mnmminanls as defined by the Buy Area Air Quality Management
,dgrirrr all new materials for inspection. Applicant understands and will comply with
°res 4!511 all non- on source regulations.
I have read the hazardous materials requirements under Chapter 6.95 of the
Cul M fan in Ilcaltn St Safety Cock,Scam.%25505,25533 and 25534.1 understand that
it the huilding docs not currnd,hovca tert 1.that i t is my mspor,daltyminch l y the .—
occu m of the mquimmcaas which math hemet prior ,,koverre of a Ce"ifivue of
° '"cy� - Signature of Applic• t Date
Dwmer . I, age., Dale roof coverings to be Class"B"or better
OFFICE