03100120 CITY Of CUPEIt'1'INOguf«yssc. �vfu,+;:b .Fw: ,s `'` 'j:�
BUILDING DIVISION PERMIT W0N1 TRACTO1QNFORMATION
maws _ ':
BUILDING ADDRESS: SON R CRASE CONSTRUCTION I MITNG.03100120
607 21
.R'S NAME: 164 GILMAN AVE PERMIT ISSUE DATE
-YUAN JIAQ
NE:
(408) 370-1485 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB mrcll
i 0, LICENSED CONTRACTORS DECLARATION
f m❑ 1 thereby affirm that 1 am licensed under provisions of Chapter 9(commencing ]Ob Description
=W with Section7000.fDivisionSofJinBusinrssandProfessionsCode.andmylicenseis rri�p�
mmu mme=na erre=` sly. REPLACE FIREPLACE TO BAY WII�DSW�1tALF,®
an? Liccnx Cl Le.a
;Pct Da¢ a Co factor
ARCHITEC7`SDECLWATION
< 1 understand my pHns sM1ml he,used as public records AUG 11 2004
tyU
U. Licensed Pr..ressiunal
S OWNER-BUILDER DECLARATION BUILDING i a$ 1 masa .(nerd on 1 vat exempt from the Contractor's License Law for the B�9q
Ca o following mason.Permian 7031.5.Business and Pmfcasio dembli Calc:Any city or county
if which reyuims n e.also m,uimx
uimxthe appliarter.cant
nt persu hPermitt Ire pair any aLnuelostatement
s—'^ that he its issuance.
ert a dpursu pursuant
to the t0nvisio cant for Condo tura file a signedata(Chapter
-0
that he iscngwidpurstion 70hc pmvivision othe f the
ntractisan ccnutaons Code)of Sq.Ft. Floor Area Valuation
i~$ (eat he is(Commencing ciefto 71and al Division sme al Businrssand Profeson.Any
CdWe)tar
.. teal Section
is campy any applicant
um and the basis for be alleged applicant
to Any violation of 3 5 6 2
notmom than fiy any for a MOBmit subjects the opplicanuo.Civil penalty of APN Number Occupancy Type
not more than five hundred dollars MOB). P Y YP
0 1,as owner of the property,Or my employees with wages as their sole compensation,
will Jo the work,and the swcmin is not intended or offered for sale(See.706.,Business
and Professions Code:The Conerac oh License law dao not apply to an owner of Required Inspections
property,who builds or improves thereon,and who doessuch work himself or Nmugh his
tan employcx s,provided that such improvements are not intended oroRcred for sale.If,
however,the building or improvement is sold within One year of aomPlction,the nwner-
huilJcr will have the burden of proving Nat he did not build or improve for purpose of
sale.).
0 1,as owner of be property,am emlusively contracting wit licensed contractors to
Contact the proper(Sec.1066,Business and Professions Code:)The Contractor's Li- _
targe law does not apply w an owner of property who W llds or impfoms Ott on,and
who contracts for such projects with a contraclor(s)licensed pursuant to the Contractors
License Law.
❑ lam exemptun/der�Sef�� B&P C for this reason
I
/mom Dow l /�
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury arc of the following declarations:
1 have and will maintain a CcniGnreof Cmucnt to self-insure for Workers Compen-
sation,ss provided for by Section 3700 of NNPerformance e labor Code,for e perfoance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by section
5700 of the labor Code,for the performance of the work for which his permit is issued.
My Worker's Compensation Insurance carrier and Policy numkr art:
Cartier: Policy Na.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE „
(Thusevian need not k completed if the I forth is for me hundred dollars D100)
lest)
1 certify that in the performance of the work for which this permit is afeed.1 shall not
employ any person in any manner so as m become subject o the Workeri Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
z forthwith comply with such provisions or this pCieno shall k deemed invoked.
Z O
CONSTRUCTION LENDING AGENCY
I heathy affirm that there is a construction lending agency lot he Performance of
3d' Ne work for which this permit is issued(Sec.5097,Civ.C.)
i1 Q Under's Name
L Lender's Atltlmas
� z /
Q 1 certify that 1 have read Nis application and sate Nat the above information is
L (• correct 1 agree to comply with all city and county ordinances and scale laws relating to
�U "nom-mentuuaction,and hereby authotis representatives or Niscity mcntcr upon hoc
W abovcmcnuunree to save to,inspectionan mer,he.
y 6. (We)acme m save,indemnify and kith harmless the City o against said
against
N in noicbeinn, fOC runhogm and cxpcnuerroo. may in any way accmc againstgam Cily /
Z APPLICANT UNDERSTANDSof Lhis AND WILL COMPLY WITH ALL NON-POINT Issued by: Date tC)
SOURCE REGULATIONS:
Re-roofs
HAZARDOUS
Signature of ApplicaRDam
IIAZARDODOUS MATE RIALS DISCLOSURE Type of Roof
Will the applicant or forum building Co occupant norm or handle Health and Safer l
..� as definctl by 25 Copeninn Municipal Code,Chapter 9.12,and the Health and Safety
Idims
Sc Yea2ss5z(a)7 All roofs shall be ins ected rior to an roofin material beim❑Yes t�tNu P P � Y g g installed.
Win the aPPlinnl or fumrc builUing occupam tax cyuipmcm or Jcvices whichIf a roof is installed without first obtaining an inspection,I agree to remove
aeardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
DYes t➢f Nu
Phone read Ne hosenha smamrials rquirements under Chapter 6.95 of the Califon
alth&SmnyCale,sections 25505.25555 and25556.1 understand that if the building
ot eurrenlly have a rettant.Nat it is my respdmsihility to notfy the Occupant of the
emmms ichmusl ipdorloissuanccoraCcrulli re fOccuancy. Signature of Applicant Date
/O /6 D" All roof coverings to be Class"B" or better
tPwIfEl m mAr odrod agent Date