00050211 CIT11 C P -
' BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 000150211
BUILDIPMQPEkSS DAVID N AND BARBARA S PERMITNO.
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OWNER'S NAME: APPLICATION SUB DATE -
• P ONF.: jf, SANITARY NO, CONTROL NO.
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O O ARCHITECrIENGINHER: BUILDING PERMIT INFO
w0❑ BLDG ELECT PLUMB MEC 11
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LICENSED
mryy jInONnuAC1JR'S DECLARATION
pZyE - Job Description
F_f-w with
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unefund eotff«UiLvisinn Joftne Business and l'mlcssions Code.end lsiy license
PULL OUT WINDOW INSTALL DOOR LIGHT AND
o.rep d V Date Ciaa Lie M y
is ca y Dae S DECLor
ARChall 'S UECLARAIeoN
h g I understand my plans shall Isa used m public recoNs
i
oC License)i'ndessiounl
OWNER-BUILDER it Ia he C1AI natra,N •
1 hereby.(S,,t Ih1 1 1 exempt Gum the Cnntmah o Anse Law Ibr the Y 1200
C ¢ rnllawing rcmon.(Smion 170315,Ilnsincss:INA I'ndcxnions h,or Any cion or county
,,F o which requires u permit m construct,alma ilnprnve,demolish,or repair eny aruqure
to prion.its issua,e,alxo requires tneapplicant ilnsuch,scminn me a.aynedaaemem
that he is lirra d,.ursuam tome provoicusof the Contmcmr's License Law tChaper 9 Sq F6ifibB1_ANa Valuation
(commencing with Section 70of of Division 3 of the Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation '
of S«tion 7031.5 by any applicant for a peanut subjects the applicant to a civil penalty
of not mom than five hundred douat.($500). .APN Number Occupancy Type
111.us owner of the pmpeny,or my employees with wages as their sole amr,wr scion,
will do the work,and the structure is not intended cur offered for sale(See 7044,
Business oil Pml'assluns Code:The Cnnoucam's Jecnsa Law does not apply to an 101 — FOUNDREI tDWN Inspections
orr of property Who builds or improves demon,and who cows such work outsell
ihmugh hi,ov,n emony«,.px vidrd Iha such impnweoentx are not upended it 1.02 — PIERS
offered fur sada.II:however,Inc building fir in.pnrvamcnl Is sold within one year ul'
mpletog
itheowner-huilder will have the hndroofprm,ing that he did and hold fir 103 — UFER -
iomprovehrrpugarseofole.). J.04 — REBAR
❑I,asowner nthe prupe y.am exclusively contracting with licensed contractors
te105 — ANCHOR BOLTS �/
onset the prujeet(Sec.70Thm
.L Business and Professions Code:) e Common's
Lwicense Law discs not apply to an own«of property who builds or improves thereon, 106 — SEWER B• WATER Q
and who contracts for such projects with a contmnons) licensed pursuant to the '
Contmduls Limo rtc Law. t 202 — UNDERFLOOR PLUMBING
❑1 an:exempt under Scc. .B&P C for this reason
owner Dme 203 - UNDERFLOOR MECHANICAL
waalceR•s coMrerv$nrdl7ry nCcLABATION 204 — UNDERFLOOR FRAME
• I thereby mrrnunder ritually ofprjnrym,corthe Following deaamtinto
' 205 _ UNDERFLOOR INSULATION
❑ 1 have and will maintain a Camficae(if Conamt to self-insure for Worker's 301 ROUGH PLUMBING
Compensation, as provided for by Section 3700 if the Labor Cale, for the
performanceofiheworkforwhichthispermitisissued. 302 — TUB & OR SHOWER
111 have and will maintain Workc,'s Coutpensatinn Inmmnm,moomaired by Section 303 — ROUGH MECHANICAL
3700 of the LuMrz Cale,for the performance of the work for which this penult is -
issued.MyWorker's Cron,wilatlonInsurance carrier ami Policy number are: 304 — ROUGH ELECTRICAL
Cameo Poli.yNo: 305 — FRAME
Ciilfl'II IC COMPENSAliONiIN.SURAION tNCiWORKERS' 306 — HOLDOWNS
mots section need not be completed a me permit is for one hundred dollar, 307 — INSULATION
al Wlorless,) - 308 — SHEETROCK -
1 cenily the,in the perfrmanove of the work for which this pemm is issued,1
shall not employ any person in any manner so as to bccutim ub«t m the Workers' 309 •— EXTERIOR LATH -
Cumpenxaun n 1 Date -/ L the
,� 310 INTERIOR LATH
NI}rICE T( I', ,:11raton1hion,this C'cmiticaenf Exemption you should 311 — SCRATCH COAT
become subject m the worker',Compcnanion poo,kions fir the Labor Code voa maxi
Oz z0 forthwith enmply wilt ardi provisions m tui,pcmdt Oulu be deemed revoke'' 313 — ROOF NAIL
.~mss CfINSI
ereisRUC a'IoNLi?fum le A(iHNCY
r � Inerenyamrrmll,mtnemiOaennahmennnlcohngagemnmrmeperfnntmnce 501 — FINAL ELECTRICAL ENERGY
� > of thewerkrorwhichthispermitisissued(Set.3097.Civ.C.) 502 - FINAL PLUMBING ENERGY
LQ Lender's Nome
p z LerdW,Address 503 — FINAL MECHANICAL ENERGY
U C I clarify that I have mad this application and state that the abuse infinumaJon is 504 — FINAL BUILDING ENERGY
coroct.1 agree hr comply with all city and county onflummes and state laws relating
o (, trbuilding construction,
and thereby n thoriecrcpmsentative,ofthiscityto at"-Pon 505 — FINAL ELECTRICAL
r� the ith-wairraimmlppe tyfill' :peer I p .e.,
y (w) g r., a _ ryawkeep 1a m„mecty ofcpenmoagmnia 506 — GAS TEST
to Iiah l t : j Igoe fs, t d expenses h may in tiny a y against said
U z City ,,ell etIt1 g t bmfdt p 'I. 507 — FINAL PLUMBING ;
SOURCE REGULATIONS.
AND WILL COMPLY WITH ALL NON-POINT Issued by: 508 — pTnlIAl Mgl;WApITC4l Date
Signature of Applicam/Comommr Date Re-roofs 509 — FINAL GRADE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building occupant some or hanme Aa mlous material Type of Rodfl 0 — FINAL PLANNING '
as defined oby n 255 2(.1? Municipal codeChapter v.hand neueannanJsarety 514 — FINAL PUBLIC WORKS
D Y`s ON. All roofs shall be inspected prior to any roofing material being installed.
Will the.,,icmit fir future haiddin,ocemnot we eTrimarm or device,which If a roof is installed without first obtaining an inspection, I agree to remove
•
e mte
District? all
air contaminants as defined by the i{aY Arca An Quality Managenrcrn
iotri rictall new materials for inspection. Applicant understands and will comply with
ores 0N all non-point source regulations.
1 have read the hazardous materials regnumnicin,under Chapter 0.95 of the
Cultural.Health&Surety Code,Swoons 25505,25533 and 25534:1 understand that -
ifthebuilJin aoeetrot currently havcamnon6 that it is my responsihility to nnlily the
Oce pan m Hent M1ch most he incl pdnr ns issuance of a Certificate of -
`' /�yf Signature of Applicant Date
/ /may All roof coverings to be Class "B” or better
« r Out o red a T'
•' OFFICE