02010101eJ
BUILLDF G DPERTONNO PERMIT
CONTRACTOR INFORMATION:
BUILDINC•ADDRESS:
PERMIT NO.
'11891 PLACER SPRING CT
OLD COUNTRY ROOFING
02010101
OWNER'5 NAME:
APPLICATION SUB DATE
KAREN KENNISON
387 UMBARGER RD #B
01/28/2002
PHONE:
SANITARY NO. CONTROL NO.
(408)362-1111
0 ARCHRECDENGINEER:
BUILDING PERMIT INFO
C
BLDG ELECT PLUMB MECH
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i LICENSED CONTRACTOR'S DECLARATION
Job Description
0 I hereby affirm tbar 1 am licensed under pmokim, of Chapter 9 (commencing
with Section 7000) of Division 3 o the Holmes, aad Professions code am my license
REROO F .
full force and eB< 3� Lic. I
c=enc
T/0 SHAKES, INSTALL 30 # FELT & MONIER TI
Qya�ae6
c 0D
%c
rfi RC TECYS CLA \TION
S 1 understand my plans shall be used as public records
DLicensed Professional
aK, OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
< following reason. (Secom 7031.5, Business and Por ..ions Cade: Any on, or county,
o which requires a permit an Corvert, alcor, improve, demolish, or repair my strucmm
_prior In its issuance. also requires the applicant for such pcmtitto file a signed statement.
- shpt I, licensed promatiaatheproAxiomofdr,CestrnomasLicense law(Chapmr9
S FLF1oorArea
s ' auction
(<ommvicing vette Scnion SO PO) of Division 3 of the Business and Ptgfessions Cade)
�`;:}".; _ (:!,,,q•'; I,D St ANI ,,.�I^'a.�w;}•�-�\l1
:
or that he Ire exempt therefro nd the basis far the alleged eiemptjbo Any violation
or Section 7031.5 by any applicant fora permit subjects the applistr acivilpenalty-
of not more than five hundred dollars (5500).
Mb
I::..: Occupancy Type
❑ has owner of she property, or my employees with wages as their sole compensation,
r
---'--- - --- - - --- ---- - - ---'-------- -_ - -- ---_ ._.
0 7 - I NSULAT l�A}I 2red Inspections
will do the work. and the stnicarm is not Intended or offered for .to (Sec 7614,-
Business and Pofcesmns Code: The Conuomor s License law does nota I
hm m
owner of prothem3
on, Who builds or improver theon, and who does such %arrk himself
ar through his own empmy`e+, provided bar mm improvements are no, intended or
_ofied
6.0.1,- -
far side :If. h�.ar-mebWaainaorimprovemais-aolawithinoneyea<of
iompletion, the owner-builder will have the burden praving that he did nal build or
af
- - - _ROOF ._TEAR__QFF.
602 - ROOF PLYWOOD NAIL:'
mprove nor parpoae or doled.
603 - ROOF BATTENS
❑Lax owns nQhe property, am exclunivcly conmaaing'ith licensed contractors
_
604 - ROOF IN-PROGRESS
construes the pmject (Sec. 7841, business and Professions CW.:l The Contractor's
11
It '
License law does not apply m an owner of,roomy who builds or improves thereon.
, '
._and.whocontmca for. such, projects with, a cormuctor(s) Iictmard.,ni smat to the
_. _.__. _.-___ __... _._. _ __.. ____._.___._J.....,____
nm law. .... .. . .
Conuanors Lia ... -
❑ I am exempt under Sec. '' •t ,BffiPCfor this rem n
- ...
_ Owner .. • Data
)� Y
WORKER'S COMPENSATION A ON DECLARATT ION
I hereby affirm under penalty ofpenjbry nne.ofthe following declaration,
''1'
❑ I have'and will mainad. a Cenifiale'of Consent Io self-insure for Worker's
Compensation, as provided for by Section 37M of the Labor Code, for the
- performance of the work for which this permit is iinuraL
❑ 1 have and will -mamdair Worker's Companeatioti Insurance, as required by Section
3700 of the Labor Cork, forrhe perfornce of the work for which this pit is
mapermit
issued. ka Insurance carrier and Policy numper are,
My W,r's C t
C t
- fION QM1WORK
CERTIFICATION rF.%EMP
I- s. 1 1) � ryY 1, } m
COMPENSATION INSURANCE
t ••(This section need not be completed if the pnmit is for one hundred dollars
" r... ' I^:':`.t ' 11, t.
00) or less,) .,
- I comfy that in the pardormande of the work for which ihnCpermita awed I
shiempl
ll not oy any person in any mannem r, as, to bootee nub)ccs to the Workers
Compensation Laws or California. Data '
_ .:. ...
... ... ... .... .. ... .. .. ... __'__..... ....... ._ _... _ ._.__ .._... ._
NOTICE TO API'LICAN'f If after inaki y tl'. Cnnilicate f E ption%you should
s
hecome subjebuo the Workers Compenzattoo provisions of the Labor Code; you ..at
forthwith comply with such provisions or this permit shall Is, deemed revoked,
r • CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance
t. s
y of the wink for which disremits is issued (Sec. 3097, Civ. C 1
,._..
Lender's Name.'__...._..,.. .. ..__. _.._..._.x.. ..c., ca ......
_ _
.... ... _.. ... ._. ... _.__.... -- - - - -- --- —
Lender's Address'
.i,•E rl.•
• 1 anify that I have read this application and state thus he above information is
c6rrecL I agree to comply with all city and oramy ordinances and state laws relating
m building conven,ctioand hereby authotiu representatives of this City to enter upon
s7 the move-rantioned.property f 'nspcct purposes, .
L' (W) g iu d ,fy dad keep hat 1tsthe Cty ofCpeninoagann
I
4 lido lint j dg ems l Cid eapaama which may in any y.,me,against sand
C car rico eq eoCline Wrumm,,fdaim,arnalt.R
" NTU DER NI -A,,p ILLCOSIPLYWfTHAtLNON-POIXT
I/ -7
Issued by: r Date Il v
SPPIIO
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graver orapphcanucomractor , - ae
Re-roofs
HAZARDOUS MAIERIALS DISCLOSURE ' -
_. ., wnm'pprt r rte ba la ng ep tnraeornanelehamard mateal
-
- .--.Type.of,Roof---
as defted! by,the CuperoM Icip it Code Chapting.12. and rhe Health and Safety-
Cwle $ ,tn 25532(a) i 1. '. - -. ..
�;
❑Y ... L7No - i .tJS f
x.. - t
All roofs shall be.inspected poor to any roofing,matenal being.mstalled.
,m Will thpoli t y r t bum g p r e eq T t o n n
If a roof Is instilled!ivithout first obtaining an mspecuon I'agree to remove
c t havaN co r t defined bythe B y Ams A' Q al'sy Management
D m t
all new materials for inspection Applicant understands and will comply with
all non-point source regulations, ..;.,,k1 t
• ', t _ I naa she hasa d s materials rey rein is under Chapter fi 95 of the
Cal foto a Health S, Safety Codep Satidrx 25505 255)) add 25534. 1 understand that
�)
' ifilbe bolding does not currently have a tenant. that it ismy nesprisibilityt notify the
'upum
_
ce or the ninic6irement, wh ch mu¢ be metp for to issuance or s Can filo¢ of
Oc:
.•
Signature of Applicant Date
_
All roof coverings to be Class "B or better
vent or iud n(-,-' : Date
g
-„OFFICE