00060076 CITY: F1&EBrpB�IIVE'..RV . .y •„ 5
' BUI UING DIV1tiION'.. PERMIT CON' TR!
fO ,O .- ,
it,; DIKCGHq H T-'AND JESSIE s 1764- NATIONAL, HVM PERMIT IWO I c
OWNER'S NAME: `�A ���!( •II A.Q . 1� �51 0 1 293-9901 ^ APPLICATION SUIT DATE
TONG'. SANITARY NO. Y� CONTROL NO.
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' p ceZ ARCHITECVENGINEFR.
BUILDING PERh1i'IINUO-
F� REPLRCE' FORTH GAL �4�GRL_FqRTErWEATgR
ad
LICENSFU CONS RACI OK S DECLARATION
os=c In nr n a r1 licensed I p fc
. r pl 9( ns . 'Job Description a. ..-
F 1-.at whls I 9Wn) fD iof ore Business
ad Pmfl Code,unanylicense
.
YS,
f III aadeff t.
a rW�a CL sC Clues ICie.ra .>.. e
.LU one 4 Contractor - ` r " r - .• r v
ARCHITFC'r'S DECLARATION e'er
f�p,� I J :mJ nYll klfh used an pr M1l'c mcords x .,k •/ / ,.•
4
w Gp,a Lite elP f ' 1 al- LI
I X - i ,OWNER-BUILDER front
DECLARATION,
w I hereby 0 m that I exempt s the C Ir l LI L r the i CP
tr a foil 6 n (Set 91yirl t :' d Pnf Inds,a y key my - ^
� p 'wh h y aD tt rl tit p 1 1,1 { Y 'r uuurc ^ • -
a 3_
Prior I I v I y r-di ppl' t h pe a 11 y d „len est -
'Nrrh ':I e dP n Ih p Ih C t t L' L (eM' IerY .SP rd
(w nrxnc'swlhSea,ea 7(XU)of oi,isinrlul the Businessland P,tdcoom Cuba)
n,' g A ",d - Va tion
• ,or(hillhe pia f and the h 1h Ilmd pt Any interim. ',• •
-
ofs I 7031.5 by ally ppl If ap t tf !the applcun . .Ips h,
ern 1 m f E do i I b ($5BB) Afig(NumbiSEWER, 1 WATER, Occupancy Type
❑1 n of the PL Iy ',ye ply m e: men 1 p , 2 UNDERFLOO PLUMBING , zr'
will d th 'k J ifI Il tintended uttered r al (S 7044, --
Bn d i 1 n Cold,: H c t t L 1 dock t apply t _ 301 —'.R000RlcgPkddMBlli"Crons
owner fp PertyWh b If 1 theJ M1 d h kh If
mutual his employees.provided a t h 1 np n nt t intended or 3�0c — TUB r 8 0Ri SHOWER _ r -
offeredf I II 1 r Ill,bu'IJI b P t .-. Id withinne y.,of
completion;the w rh Id llha,all burden of v'ngmmhedid net buldnr 502 -- FINAL' PLUMBING ENERGY
Imp- f pnrPesC of vale.). s
" 506 GAS•.TEST'
°1 f Ih p tic ty --'n IY I f tl 1' d 1 to.
an.t n1 -v J Its 7044 BIs'ne dPiero..o..0 I)TI c rloal ..'507 FINAL PLUMBING .
{
License Law does not apply to all owner I p p )y who builds or ral lea a
and h m t. f h p j 9n"in a t acami s)licenced re su ml m tl c - ♦^ "
Coanlrx L,.a,cL-
°I cearlunderS f:- B&PC foi lhisr assn ^ ,
_ .
Owner - DateF_ _ -
W'ORKER'S COMPENSATION DECLARATION - - v i✓E 1. '
,.0
Iperch thus undcrscull fPerjury
e $ 1
y r I yep ju y meet the fall ung dLvlaarear h t
,
] have endtw II nn na n t"C,Bil cam of Consent•to'elfnsure ftr Wor$cr'F
maps rsnFn y n x deo Pon p '-Seeded 1700 of the Labor Code,.for ahe
s poO . .r. . .
perrnrmrace of lho work ler wnmN ism permit is ixsucd.r • '
❑Ihavead 'Il n t W k C pL 't 1 u' -9 dby5 I , • " -
3700 f Ih Lab b Cod tirep 1 1 Ih k t I Ih p r s "
Issued.My Weaker..G p - t Ieuros ',•t.1 Policy number
Car, j.
�ln1'le
YN Cr/�LQWt/V�l/ ,r
CER rIPICATION FFXI.MMIO I MWORKERS' "
.
C MI NAT .. .
O E 5 ION INSURANCE
(this section need not he centered!if We permit is Ear one hundred dollars - ^
1$10(por leen)
I rarity bar Ih ",I,
t Ill kf I' hII pc I'. di - -
hnll I cartel, y PL t b m rA Ih W k ,
comp t n '
NOPICF BOAPPI 11 (Ikngih C«1 1 IL It y 'E Id
� Oneo 1 in,n I W k C p ,a p ftp L b Code yin I _
forth lh comply with such p i l s or tl s permit shall lx.deemed revoked,
.z - y
V1 - CONusRIICOONLENDING
nifin, Y - a, ,
•,�P' Ihcrehy often rh nh ,nachos le rdlg ape yf thepriorm c r.
ti ofthework orwM1c this pen tie veoed(See 3097 Co,C.)
,a G Leid N c
Vz Lends :Add se
1 tf)that 11 hall tya i and LI21that the id above information
car o1gy 1 ply ,.Ill all 1ya 1 lY J d stateIi b n
O mb'II g r f dh by Ih > p t t ftp': 'ryt ser Ivo v•
ins n is d .';
Or (W) e , property
df 'fy dk phP I.'.-th ClyorCafe
«
FF�� VJ Ilub'llf 1 d6 I t d 1 which y In any nY a" me amidst d p'
V City c91eucofd gmrdixrllh I C pp .
APPLICANT ENDERS SAN WIL { LY,WITHAL N NPO
Issued by: Date
soURCE REGUTA9 N �eY
_tii� —
Ble 't t APBI n/Ot nim 1 Re-COOfB
HAZARD US MATE RIALS DISCLOSURE a t
Wad -ppl t t f t h Id' e p t.t orh d1 'n :m e rNnu1 ..Type of Roof, . . t -defined -
sbyth Calcium.M ),ICd Chaplet9,12 ITh Health and Sfty -
- Cod Samoa 455320
°Y -All roofs shall be inspected prior to any roofing•material being installed.
W,11 It apowant 6 i f B P I devices which If a root IS Installed without hrSt obtaining an In spectlon, I agree to remove '
eWith d - t t 'df {hylh ByA Area Quality M g , Y
Heated _ all•new materials for inspection. Applicant understands and will complytwith'
°Y s - all'noti point source regulations `
' Ih read file hmaterials 9 ts ander Cl per 695 stthe
1 rF .
Caldernin Health la&Safety C d S t a 25505,25533 an,125534.I raiderstarelthat
'f0 b Idia,J t Ily tat' I I that I'. ) p bllyt if the
Le p' t f Ih 4 L w�ch null b t p Io ins 1 Caoificate 1 w _
Occ p Y .,. '
Signature of.Applicant Date.
Os -air ere¢ am , - DlV V 'All roof coverings to be dass 13"dr better