DEMO PERMIT CI BUIONRTNNO
NG DIVISION
IVIPERMIT CONTRACTOR INFORMATION:
BIIILOING AI]ORIiSS: PERMIT NO.
OWNERS N'ANIE: — APPLICATION SIM DXIF
•PHONE: SANITARY NO. CON'1'ROLNO.
rr
a O O ARCIIITIiCI'I-NGINEFR: BUILDING PERMIT INFO
u❑ BLOC, ELECT PLUMB MECE
FEW CUJ t=1 1_1 1=J
F N j LICENSED CONTRAC'TOR'S DECLARATION .lob Description
I hereby afu m'hat 1 am licensed under provisions of Chapter 9(countering
-I cu win Seri on9tID10ul'llivl,ion3ofinellncine,c and Pod—wo,Cale.and my license
Y I-in full farce anA club'
zw¢ License('J�.s�{] Lic.l ,` � f� mfyyyq�„
O a U Use' [�ZG)/73/ Cnnlnlctnr_:Sze til 3 a.G ARCIII'IECI'S DECLARATION
t-a C 5 1 understood my pl:ms shall be nsed as,imhe wand,
us
waso O Licensed Professional
OWNER-BUILDER DECLARATION
w 'eI hereby dfna unit 1 on cxnnpl•I'Innt the Coulmolor'e Liccnsc Lnw t'or the
Following reacssm.(Section 9031.5.Businecc and Profs—Code:Arty city oramnty
2 O which minims a pem(it to constrac4 aIle,improve,demolish,or repair any stractumas
�(
WL$ prinnn llF ln,nunae,nlFn requllcs the applicant lir such permit to tilon signed Ftmmnenl
that he isilemcd pursuant to dw provisions of the Commemei License law(Chapter 9 Sq. FL Floor Area Valuation
(contmevcing witn Seclin 1701 of Division 3 of the Rasion and Professions Code)
nor that he is excntpt Ihemnifit and the basic lir the u11,,,d eacnlptial.Any v4,1.lion
of Section 7031.5 by any applicant for a permit sub cies the ILPIXc cl u,a civil Penally
of not more than Five handred dollars( 500). APN Number p,.Tncy Type
❑1,is owner ill ml pmpert3,nor Iny employees with wages m their sale compenmtinn.
will O"Ibc work,and Ihe"roman is out intended on otmmd for rale(Sec.1144.
12 mad Prileion,Code. the Com.. Llecllcc La.dies not th,,ly to al, egmred Inspections
owner of property Who build.,nr improves Ibe.,..and no docs such work himself
or Ihmagh his own employees.provided the such improvements arc not intended or
offered For sale.If,however,the building or incloosenu,no is cold within torc yelor of It•1� ( IIIHI ID) III1 fEltvlfIImlt
completion.the owner-builder will have the burden of proving that he did not build or
npnwe Ice warps..ill'cede).
01.as owner of the property,am exclusively contracting with licensed comrwmrsm
Licrvct the proic,l(Sec.1144,Buc nd Pmfe,F F Code:) The Contrail
e e law doe not apply a .,seal pr,coy wln.tbui Id or improve,Ibemnn.
and who conliact%for such pmjems with a comrallots)licensed Forsworn the
Conor.ods Lcen,c Ww. -
❑1ainmcmPtunder Sce. ,Il&PC fm this ma em
Owner D.Le
WORKER'S COMPENSATION DECLARATION
I bcrchy uffum under penalty ill'Perinry ane of the Following declarations: _
❑ 1 have and will maintain a Cenifica¢of Consent to self-insure for Worker's
Conp,culad(n, ;is provided for by S,vton 37q uI the LaM+r, Ctzlc, far the
performance of the work for which this permit is issued.
O 1 has n I will n Inndn Worker's C'umpeusatioll Insurmwe,as required by Section
31110 of Ibe IaMn Cale,for the crl'nnnu rs,of the work for which this permit Is
ix.,ued.Ms�]p'%%�Wo kcls Con No hot Insurance canier�and
•�Policy handier am:
Cejfl,r '� •.7 Policy No.: Zsz—y---
CERTIFICATION OT EXEMPTION pkOM WORKERS'
COMPENSATION INSURANCE
This ecation need nor be cnntpleted if the permit is for one hundred dollars
1511x11 nor le.+.l
1 amity that in the performance of the xor,for which this permit is issued,I
,hull not enq,I,any Iverson in any(nunner m as to been..subject to the Worker,
Compensation Law,of California.Dale
Applicant
NOTICI7'10 APPLICANT.Ilatllcr..king Illi,C1mf1o1c of Esc updon,Yeo should
hero cc larbject fo the Wodefs Conw
gnsntinn 11,11 na.,of the Lvbm Cade.You noon
Q O l mmilh cnntply wim such provisions in this Permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I herby a1Bnn Ibal there is a construction lending agency For the performance
the work air which this penna,issued(Sec.3091.Co.C.)
ms's Lcnder's Name
D z Lcndcl'..,Address
C.) 1 certify that I have rad this application and slam that the above infommtion is
W t^rair.... I agreeiln cnnlIll,with all oily sad enemy..Nina..,and Fno,law.,relining
V mbuildingmnmm,ion.end hereby uuthnrim rcpre,cntntivca if lhlF uhY to cnmr upon
rNw,uncro inn,pmpeny fur impcction purfxne,
(Wc)a,me ti s:we,i1 rilyund keep hurtnle,c the Cityof Cupcnione,hot
V] liubillic.c.Fall ms,co,Is and es cn e,which may in mrY way accrue apuinsl said
U Z City in.,nap in , Ihis permit 7/'J —O
Sf11tICERE,11N1 . OPA Ih .COMI'LYWITfF� ONP Issnedby: ze5�—
silaoinne Date �(/of Applicu co .Ivor Ume Re-roofs
IIA% RIHlUS MATERIALS IIISCLOSURIi
sun me appfeant m fimre hnimmg twvmpant Ftnm an nanme naaatdma,mamdd Type of Roof
as dclincd by the Calverium,Muniap:d Caw.Chapter 9.12,and the Hcdm and Sickly
Code.Svntion'8532TO!
El yes• 0N All roofs shall be inspected prior to any roofing material being installed.
Will heappllclmtormore boildmgueupanlmeequipnanlordeviceswhim If a roof is installed without first obtaining an inspection, I agree to remove
colt humrl,us air contaminants as dernm by the Bay Ara An Quality Nlanagement
Dislrierr all new materials for inspection. Applicant understands and will comply with
. Oyes 0N all non-point source regulations.
I have read the humrdnm Ila ncn el,mutant, cal,wader Onto,,695 of Ibi
California[Icahn&Safety Code.Section,25505.25533 and 25534.1 understand that
if the bili) doesunlecroe yhoeuonunt thm it 4,,c my raqu,cibi ify to nosily the
ecupunl o mF which moat be a"pilar lu IµFunic,of,C.Illllcme.oF'
Oven ney' G//!' " Signature of Applicant Date
wnenrr aamidred agent - 1 All roof coverings to be Class"B"or better
OFFICE