01020129 crr�t
o TFo'it�M1 u)tVFaONNo PERMIT CONTRACTOR INFORMATION:
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BUILDING ADDRt-e0!T,0 S DE ANZA BLVD ,-F PF.RMITNO. toff 7.Oc'kD1.2
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OWNER'S NAMF1i I MPTCN 31101a1R "z-r , ,. _ .. APPLICATION SUR DATE
�IONE. •SANITARY NO. CONTROL NO.
aCA- 9"110H
D-z-L ARCHI'1 FiCT/ENGINr:ER'. BUILDING PERMIT INFO
pj •' BLDG ELECT PLUMB MECH
FzG I—U I� IJ CI
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Z y c I herehy affirm that II Iit CO coo d under provisions provisions otf Chat, 9(commencingJob De$CI'IpllOn
° wanfuaron]andan Division].nneBa%ia,%add Porex>it c�nemyficenEST-1MATEDc FEES :
m ] is in full force and cfc.1 q
z z 6 License lath Lic.a �.! -
X;ea Dme _ Cnnlraclnf-
LLI rAItC I WT'S OISCLARA rout
C n 1 unJennnJ my plans shall be used us puM1lic ren,rJ,
EWi,_
WC O O Two..ed Prol...oral
°'u o� OWNER-BUILDER DECLARATION
I herehy affirm he,1 nm exempt fn; I,he Connector,License Lie.for the
F z s' loduvving reason.(Saaion 71131.5,Business and Professions Calc:Any city or county
E F G which requires It permit to enmtma,alte,improve.deri or repair any swcma
(e,3- prior o-,it....uauec,al.n remlinsdae.pplicant for such permitw file a signed smtanent -
"mat he is licensed pursuant to the provisions al the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
frommencing with Section]ap)of Division J of the Business and Pmfis,Gohs CeAc)
or that he i,exempt mercfrom and the basis fir the alleged exe;nption.Any vlolanon - 'S$-3000000-
of
3fjl00000-
ol Section 7031.5 by any uppi ward for a pemai,subjects the applicant to a civil penalty
nr nth mpre man f.e nanarea aauan(,Sunt. A PN_Number Occupancy Type
❑1,us owner of the pmperii or my employees with wages.,thci,wic ornpemmi.n. r6S�1'itry6�" L
rill do the work. J he matuare is no,intended I,officred for sale IScc ]0.1x.
Bi d Pofle,,i I,LidCide I lie C t" l . I i •nw Low doe, I apply to an - Required Inspections
u e Iproperty Whob IJ. p thand who J such work himself 516 FINAL BUIL, ING
nand
.yea,.th..apt his own annyecs.pnn'ided that such ampm
nweem,are not intended or D
offered in sale.ll:however the building or Irap.,ramaa is sold wi,h'm one your or
completion,the owner-builder will M1mx But burden of proving that he did no,build an
improve for pnrry,se nisme.). -
❑1.as owner of the rruNnY.an)exclusively contracting with licensed contract
Lnro
ame,the project(Sri.]IDG,Basions and Pfensinn,CaluJ The Cord, 's
icense I.a%docs not apply to an owner of property who Wilds or improve,ancient.
who and wwcommasuch for ch projectsmtra
t.with a naogsl licensed punuan,to,M1e
n ho c Liwnsd Low.
El 1 am e,ampt under Sec. ,B&I'C fnr this rez \
Dwner Date -
WORKEWS COMPENSATION DECLARATION
I hcreny aallinn under Imnulay of perjury one of the following dedurmion.¢ o/ •
O I bwa and will provided
n a Cby Se ti of Cons cat In sd Labor
sure for forA the 1
Cmnpnnince of he provided for by Section si... of the LoM,r Cale, for ,he
poRonnonce of the warA for which that permit is absurd. ,
O 1 have and will nminmin Wnrker'n Cnmpensx,ion Insurant as required by Sectionf�.
J](p of,he Labor Gds,for Ins n laser mntc rr the wad far which this pemti,i,
nod.My Labor
oro.f r be Inavane carrier w Policy number are:
✓ ( SPP—P.1 ry Na�6�(j jZ�{1.30 0
J`• CERTIFICATION OF E%EMFIION P JM OR BRS'
COMPF.NSA'I'ION INSURANCI?
(This sc,,ion aced not la I ,,load it the permit 1,fur one hundred collum
(511p)nrle"T
I certify Ihat in the pedurmanm of,he work for which,his pemth is issued.I
%hull no,empluy any perste in any another w a,to becmne subject to,he Workers
Compen.anion Laws of Caliromia.Date
A,fwam
NOTickiTO APPLICANT:If,.ter making this Cenificme of Exemption,you.bould
bceanm,ubjm u,Ins Worker',Contpcn,uuon prt"Won,of the Iaho,Code.you.oast
Z
0 timhwi,h comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby or which this Permiere t is issuedconstrce, lending agency for the performance
Lethe cork for which,bit Penni,it issued(Sec.309],Civ.C.1
ty Q Lender'.,Ni at
'
= Z 1<nlerAddress
AJJrco
0 1 certify Lha,I have mud thi,np,h,rlimI and one the,the above'mkonarnion is
[r rnnm,.1 agree m comply with all city and county nNiwnce.,and ,are law,relining
C.7
to building conumetion.and hereby not hnrl rc rcprc cntneve,of lhi,city lu enter spun
the a invomemioned pmpenY liar on"e ion pm Paw,.
y (w'n)agree msave.inde 'Mic and keep lowit mdcss,ht City online a'aim,said
Z City is r......q memo coal and<xpcme,wean may in any way accrue ngainsl nuiJ /
U Z City in emt,eyaena gime granting nrthi,prrtni,. '
API'1 ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
of '.lxoul. �— �ZZ�I Issued by: Date"
isnamre�r Appfa. 'nmmaar Date Re-roofs
HA'/.ARDOUS MAi ER1ALS DISCLOSURE
Will he upFficam or older building acupam core or handle ha.,ad n,material Type of Roof
as defuse by the Cupenim Municipal Gee.Cla r9.12,and the Ib m,b and Safety
Code.Sarin.255320)'! -
°Yc, CI No All roofs shall be inspected prior to any roofing material being installed.
wu1 ntenppfean,nrmmrehailding,neupnm.,stp;pnomnrdevice,which If a roof is installed without first obtaining an inspection, I agree[o remove
mit havNnw air cnnnminan,a,defined by the Bay Arca Air Quality Management
'oYcs 1:1 No all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have read the h,Co w,. martial, 505.25533 a under Chapter G 95 of the
if
buil in do&Stray Cole,ave a m23303. its add 15534, unJemmnd thud
if,hebullor he ,currently havein't be Ihad Pdo,my"daresihllcConMfy the
a t nl the men,which sun„be lost prior w iawtmce al'u Cenilicam of
n Iter
�-^- �.,•z2—O� Signature of Applicant Date
o-tmIn a, araeedastnt Dat. All roof coverings to be Class "B" or better
OFFICE'