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OFFICE
CITY OF CJJPF,RTINO
'atftiatnNG mvtsroN PERMIT
CONTRACTOR INFORMATION:
:
ITRMIT NO
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JBIALDNGAOURESS
WNER'S NAME.
APPLICATION SUB DATE
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PH 1754 NATTONAI_ AVE
1.1./17/2Q'00
ONE:
SANITARY NO CON IROL NO
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ARCHrIIICI' /IiNGINF:Ek:
BUILDING PERMI'I'IIED
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BLDG- ELECT PLUMB MECH
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LI CENSED CON'TRACTOR'S I ECI.ARAI'ION
Job Description
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flter.byartlmtm ;,n am lirensedumin,prm ;im „of Chapter nlcamneoddng
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with Scsainn 7mXB of Uivisinnl nrthe Huwinms nnJ l'rofcsdnns Cade.madntylmame
is in full force and effect.
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Dare SDEC A
Akl'lll'l1iCl "S UEChARAI'ION
REPLACE 75 GALLON GAS WATER HEATER
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1 laid .... 1i my Im"I all wooed m public reo,ch
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LicLicensed cen, Professional
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OINIER-BUILDER UECLARAi'ION
I hereby affirm that I ram crimp, from Inc Cnmmcmr, Liccme L.w for the
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following mason. (Section 7131.5. Huxiness and Prefessions Code: Any city or county
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which ryuifes a permit to conawet, alter, improve demolish, or repair any structure
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prinrIII III illwali. Ill. pliml dwappincent l 1 la,nalt to rile a simid Lstatement
Sq. Ft. Floor Area
Valuation
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main Ip It Ilm p ohs f Ilm C lanulor, r Law Clm,w,p
fu,mne,a g w Ih Statute 7111X11of 1TV'mian 3 of the Ilm c, and 1'relb,e , I, Call c)
or that he is exempt therefrom and the basis for the alleged ewnipdon. Any vielmle
of Section 7031.5 by any upplicum Ins a co mi, wubjear the applic.nno a civil penally
APN Number
OccupoIlly,,�Te
of nor meIll.. rise handled dohata($500k
❑ 1. property. o . m l
nthen ark.
shim isployce<w intended or offered air(S c. 7W4,
will do the wmk, and the ode:Ire is not oor, Li or a Law tPc talc (Sec. 711•td,
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tuts ,i Cmnmmort License Law men m,t apply rn w
nr
32E 180E4w �&puired Inspections '
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of aaJ who does such wink ni
of pert, Who With or rtlEd
d r ...It
Nat each impn,a' ed
ar mmufM1 a, ow arc not intender of
own emPever,
t. buildcd
is sold
aRereJ for sale. II: htmcever. the hnilJing or itnpmvemenl is tuts within one year at
sal
completion, the ow net Wilder will have the burden of proving that he did not build or
502 — FINAL PLUMBING ENERGY
irr"o c fur'loram
506 — GAS TEST
❑I.a ,w; ofh property.... cadusmdyeoareming aim Illenud eontrtctons le
siun a
thrum theenPrnie„ (Sec. 7094. Bra, and Proles s Code:) The CI trach"
507 — FINAL PLUMBING
.ad wh Law tract ram usury m aft nr property who halide e hap roves ax
and elsw t to the
e%Liects nor such moiens who a sommetnf,) licensed parsvam m me
Commons. License Ira.
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❑tutu exempt unJCr Sec .Bkl'C for this reuwn
Owner Date
WORKER'S COMPENSAI]ON IICCLARA'T)ON
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I himby III! rnt under Penalty of peep, anc of he following declaration,
❑ 1 have and will maintain a Cenificme of Comcm to welt - insure Pon W'olate,
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Compenwation, as provided for by Section 370 of the LaWr Cale, for the
performance of the work fur which this permit in issued.
❑ I hove and will naintem Worker', Compm ,III on Insurance, as malulred by Section
3700 N me labor Code, for the pah,rniance of the work for wltich'this pewit is
issued. My Workers Compensation Insurance carrier and Policy number arc.
Cartier Policy No.:
CERTIFICATION OF EKE,MM [ON FROM WORKERS'
COMPENSAGON INSURANCE
(This seminn acid not Ic mmpinad if tire pcmait i_, for one hundred dolla ,
.
($10(1 or lest.)
I certify ohm in the hrm r ance of the work for which mo. permit is issued. I
chili net employ any Person in any manner s) as to become subject m the Winker%
Coonpcmmion Law, of Califemia. U.n
A"li'am
NOTICE 110 AI'PLICAN'1': IL anct making Ili, Certifier, of Exctnptlnn, you ,hnuld
nec mm subject ,, B¢ Walker, Contrynmtion provisions of the Labor Code. you most
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forthwith comply w,in etch pookiom o, thin Permit shill W lamed re voked.
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CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction finding agency for the performance
of the mark for which this peen ;t is issued (See. 3W)7. Cie. C.)
GLender',
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1 anify that 1 have read dui, application and state that he aWvc information is
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cortex. I agree to comply with all city and county ordinance, and state tans relating
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to Wilding enmwetion. anti hereby oumorim representatives of this city m enter upon
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the ahnvo-ninflotel property lbr inpectiaa puopo,es.
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(We) ttgrm to nave, indemnity mod keep Lrndc,n the City Lit Cnpeniao maiw,
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hahilit let..... a enu. coat, and c,p,oc, which tnuy in any way a"we a'aaal said
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City in tmm.ayucncc of the gnn,ting of this permit.
APPLICAM UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dale
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SOURCE. REGULATIONS,
Signature of Applicant/Contractor Date
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
' will non nppn�nt m Baum nuruding oa,tpatn story a, hanme nnemlon, a eacnial
Type of Roof
as dewed by he capenim, Municipal Cmk. Chapter 9.12. and the Health and safety
Coda. Section 255320)'!
❑Yes 0No
All roofs shall be inspected prior to any roofing material being installed.
Willthe applicant nr thrum huiming eacupant me eyaipmentm device, which
If a roof is installed without first obtaining an inspection, I agree to remove
nd ha,.00u, air umtamimat, as defined b, the Buy Are. Air Quality M,mi,ro ate
D,stdee
all new materials for inspection. Applicant understands and will comply with
oyes ❑Nra
all non -point source regulations.
I base read the haaamlou, somerimt requirements under Chapter 6.95 of the
Califomia Health A Safety Code. Sections 25585, 255)) and 25514. 1 undemmnr mat
If the W ildmi, dues not currently have a tewet, ohm it is , ,'re,pt—ibilily to notify the
occupant of the requirements which must W me prier m issuance of a Cromr,re al
O'capancy.
Signature of Applicant Date
All roof coverings to be Class "B” or better
Dane, o,. hill raa,ed.,cut - Dmt.
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OFFICE