01040032 ct TY OF
NG DIViN
PERMIT CONTRACTOR INFORMATION:
BUILDING ADURESS: - PERMIT No.
6379 ATHERWOOD AV DIJOSEPHS PLUMB'IN 010A0032
OWNER'S NAME. APPLICATION SUB LIArE
JENSEN HOWARD hl AND GAIL A 1.54 WYANDOTTE DR OA/09/2001.
HONE: - SANITARY NO. CONTROL NO.
(408)-365-2058
not.no ARCHILECTASNGINEPR: _____7BUILDING PERMIT 1' )
a, - BLDG ELECT PL MEET
y.a i 1=1
LICENSED CONTRAMOR'S DECLANAI'ION
1 hetes nim,that 1 m licensed under ns.,f chat 9 n ' Jsob Description
a_ r a provi%io r {c p, song
zv_o_w wins Scainn]qXq of l)ivi.ewn J of tM Buvney..an .iQh./: .J ny license t a
m y= in full fV n1Lef t. J f (/ / 7
Nl< ❑em clams x _ REPIPE DOMESTIC HOT 8 COLD WATER PIPE
X
at.
= ume cAntraenr
ce"v ) C111 :Cr'S DECLAM,rl N
t_-=O I 1 unfr+mnJ my plans shall be used as public records
EL,p 5 Licensed Prole%ional
Gat I a -BUILDER m the CoATION
._1 1 heathy affirm on I ata exempt form me Comrxmr'x Licence taw for the
=E< following rcawn.lsectinn](1}LS.Iluxinca and l'ndessinnz Code:Any city or county
2 n which requires a permit to construct,alter,improve,demoloh,or repair any structure
i3 Ce prior m its issuance,also requires the upplicart it such Permitto file a signed statement
that Ni is licensed pursuant In(he provisions of the CtmmOnrs License Law(Chapter 9 Sq. FL Floor Area -Valuation
(commencing with Seelim.]00(d of Dk i,inn 3 of the Bues
sins and 11fim,ions Cade)
or that he is exempt therefrom and the nasi%for the alleged exemption.Any violation
of Section 7031.5 by my applicant for it permit subjects the applicant n a civil penalty
of not mom than rive hundred dollars($500). APNI Number Occupancy Type
°L as owner of the property,or my employees with wages as their sole compensation.
will Jo the work,and the manure is not intended or ofered for vale liver. AW,
Business and 1'roh,sims Code: [he Comments%License law does not apply to an Required Inspections '
r or pmpnrty Who build,or imve
pro ,thereon,and who due,such work himself
or through his own employees.provided that such improvctmnts arc not intended,or 202 — UNDERFLOOR PLUMBING
o0cred for sale.If,however.the holding or iinprn abouts is sold within one year of .
completion.the owner-builder will have the burden of proving that he did net build or 301 — ROUGH PLUMBING
improve lin purpoa of,wlcl. -
❑1,a,o .noflive puseny.nmexclusively eommeient olilicensed eonuvcost,le 502 — FINAL PLUMBING ENERGY "
naruet he powlt Is ,nus.Burin,,and P,ol. codec Tne Co.nmm
ery 507 — FINAL PLUMBING
Loicenxc Law doe,nor apply ,,not owner of property who n,btdlds or improves thereon, -
end who contracts for inch pmjectx with u umlmclirlx) licensed pus wont m the
Commena'e Llcensc Law.
01i ex nnpt under sec. ,If h P C fit this haat '
Omer D.nc
WORK17RS COMPHNSAI'ION DITCLARAI'ION
1 heathy aBln6 under penally oa,
f perjury one Anne following dntrarns
o :
7
Qm,(1 nava unA will nminiain a Ccnilicutc of Con,cnrm sets-innura rat Workcr'e
eavaoical as provided fr uby Section 1]110 of the Labor Code, bur doe
e per[mnance of the work for which this permit is issued.
°I have line will n,ainelin Worker',Compen,mion huunne,is regnired by Section
3700 of he Labor Code.tar he perlonuume of the sunk In,which this permit is
nsueJ.MY 'Arkcrs Cnrn1< sdos InIs —eca-rt/y'�r�'std rite pyheram 3 -7-
Carrier: I'nlicy Nu! 1•GJ. ( (Y7Q{'/ �A
CERn19cAri oP i"TO'TION FROM WORKERS _
COMPENSATION INSURANCE
(nein section need not be competed if the permit is for nuc hundred dollars
IS I W)or less.)
1 ccnify that in me performance or the work for which this permit is issued.i -
shall not ennple,any petsm in any manner at as to become subject to the Workers'
Compennmion Low%of California.Dane
Applicata '
NOTICE TO APPLICANT.IL after making this Cenifimm of Buminion,you should
Z become subject to the Workei%Compensation provision%Kit he Labor Code,you must -
O forthxth comply with.such Provisions or this permit shall M,earned«stoked.
Z �
E lin CONSTRUCTION LENDING AGENCY
'I thereby aRmn that them is a construction lending agency for the performance
of he work for which this permit is issued Nev.3W7.Ci,C.)
6. lir Lender's Name
D Z Lender's Address - -
QI certify that I have read this application and swm that the above information is
ECe. rrect.I.agree lin comply with all city and county ordinances and%late laws relating
U to nuilding construction.and hereby amhorize representatives ofrhi%city to enter upon '
w G: the above-rmemlnoed property for impection purpmes. '
E.. fl. (We)agree to stave.indemnify and keep hannlcsa the City of Cul,eninn agaimt
n liabilities,judgments,costs and evpenxes which may in any way accrue against said
UZ
City LIIXto consequence UNDERSTANDS AND
t.Permit.
APPLICANT CANT UNDERSTANDS6ND ILL COMPLY WITH ALL NONPOINT ��
sou PRE IL nords, e f Issued by: Dale•
J(,t sea i
j$'tgwn re o Ap,l canuCourmcmr Date Re-roofs .
HAZARDOUS MATERIAL DISCLOSURE '
.Will the applicant or future MtiWing aeaboul lam ur handle hmandous mamend Type of Roof
as defined by rhe Cupeninn Municipal fixe,Chirpier 9,12,and the Health and Safety
Cale,Section 255321ar!
°Y`, °No All roofs shall be inspected prior to any rooting material being installed.
Will meapplor%Aormnmmuildlmgiaealamuse c:rvipmcmAtde%ices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hazardaus air corta index as defined by the Bay Area Air Quality Munagenmnt g P g
.arin'r . all new materials for inspection. Applicant understands and will comply with
°YeV ID No all non-point source regulations. PP
I have rens rSa Safety
Coje,mated:,, 505.2 stents lander Charter bey of the .
it be build Hmtlth Nr...I nu Pods,Sucaonx 25505,15539 y b 25534.I undcrsnnd That -
inhebuddingesusnot .ecor, yhaveamnnm,thatitis soy r01 one, ,onewe of Arymtirc,,the '
<apanr Af ane regahxnnemn which nrnnl be rr,el friss m i,nrrrrnAe it a cenmaare Ar .
&""
�j�� �f Signature of Applicant Date
�/ " r
2ACneaatm�rreed aganr All roof coverings to be Class `B" or better
OFFICE