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BUILDING DIVISION PERMIT <<,vtv i acri%.; 1 ern gL1Ur,Vnlvgt,]1`l�
BUILDING ADDRESS:
OWNBR'SNAME:
N/C • amu' i /•r/ v! %✓
1514
ARCHITECT/ENGI.NEF.R
LICENSED CONTRACF0R'S DECIARATION
owns
I hereby affirm that 1 tam licensed under provisions of Chapter 9 (oumaxamemg
with Section )Opo)Ol Division 3 of the Business aM Nadcru is myli«mcis
in Nil form and alien. y O!
License CI s Lie. N
Dose — Co...,
ARCHITECTS DECLARATION
I undemratd my plans shill W used a public records
ZGA30
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby am. shah I atm exempt from the Contractor's License Lnw fm the
following reason. (Section 7031.5. Business arta PIartasu ns Cade: Any city oe county
which requires a permit to conswek altar, improve, demolish, or repro any reassume
Mor to its issuance, also rtquims the applicant for such pemut to rile a signed steamers
that he is licensed...... m the previsions of the Contrecrora License Law (Chi 9
(Lion aicing with Section 7000)of Division 30fth. Business it PRlfonixto Cod0m
that he is exempt therefrom and the basis for she alleged exemption. Any violation of
Section 7031.5 by troy applicant NO is mbjecs the applicant m a civil penalty of
•�
Beni,
I more Nen five hundned dollars ($500).
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Las Ownerofthe property. or my employee. with wages as de..Is compensation,
,
will do the work, and die structure is Trot intended in offered fm We(S.. 7044, Business
and profess.... Code: The Cos.,.'. License law does nor apply m an owner of
property, who Wilda or improves Merton, and who does such w.h himslf or through
his own employ.,, provided that such improvements are ret inandW or uttered for
We. If, however, the Wilding or improvement is areld within one yearofcomplation. Lia
owner -Wilder will have the handle. of proving that M1e did not Wild or impmve No pur-
pose of wide.).
❑ 1, u mrser Of the property. am exclusively contracting with licensed contractors to
construes the project (See. 7W. B..iras, and Prefeuivns Cede:) Tia Contreclors LI-
ce.., few doe, ret apply to an owner of property wbo Wilda or improve, diercov. and
who contracts for such projects with a co enscmrts) lic,nscd primate in Lia Convaclola
License law.
❑ I am eaemq under Sce. . B k P C for this.
Date
WORKER'S COMPENSATION DECLARATION
1 he chy silly. uidtt perW ry of perjury one of Liz following decWeduo..:
1 have and will meimum accru i.t. of cuseem, to sclFinwre forwo ioue.comgn-
ution... provided for by Section 3700 of the Labor Coda. for the pmfomia«e of the
w k for which this Brom is issued.
I lave ane will maintain Werker s Compensation loommce, m nsquird by Section
3 ofthe labor Care, far sed grfonls«e of she wort for which this permit is isssuged.
Ceymcr: ,f ��'r'/Cs.0 policy armermil l o�yIACZO Ia&I ✓
CERTIMCAIEOF EMP'nON FROM WORKERS'
COMPENSATION INSURANCE
(This,axim xed nw be camplelW :fila pemdt is (.none M1uvthad dollars (5100)
or less.)
I employ
my Bus in the mynommer .f the wok nxa cu ch,u, do, W is issued l shill
not employ any person in soy mmntt ...... Wwme eubjecs.. the Worker' Compcn-
Appli Laws of CJifvmia. Dora
NOMCnt
NOTICE TO APPLICANT: If, afar making thisCertificate
vis: n s o of Exemption, you should
femme h.., m the Workers Compensation previsions of the tabor Code, you most
fonhwiN cmnply with such provisions or this gmiit shell bo decreed mak W.
CONSTRUCTION LENDING AGENCY
Q(hereby affirm lost there its commicuon lending agency for the performance ad
rZi the work for which this permit is issued (S«JO99, Civ. C.)
F. Lender, Nem,
Wi > leaders Address
W E 1 certify, that l have reed this application and stale that the above Information is
0.coral 1 signs, to comply with all city son canary ordinances son state laws missing in
D Z building construction, son hereby eulWtiu representatives of this city to enter upon da
V C) above-mentioned property for inspection purposes.
V. F (Wc) agree m ave. indemnify and k«p hvmleaa Ila City.f Cu stiles, I
C V lubilidcs,judgmens.crosand..pensee which maY in anY weY,«mea id City
} Iki in con aeon" of the gmndng .(this permit.
[... Q .l' UNDERSI' II.L Ca MPI IALLNON-POINT
(.i SD ERrGUI
Sigratme of ApplicanVConsacsm Date
HAZARDOUS MATERIALS DISCLOSURE
W II the applicant or future Wilding «cupant start Or handle haeado.. Inssasl
a defined by IW Cupcninon c WI Coda, Chapter 9.12, and the HWth and Safety
Code, Section 25533(e)R
❑Yes �No
Will the applicant or (mart Wilding «cupmt use equipmem of deices which
emit hermit au reruns: or defned by Ne Bay Nee Air Gaudily Managemcns
isvim9
❑Les N.
1 have Iced Lia haaardo.. maariata nsyulrtmcns under par 6.95 of the Cdi-
(omu Heel efery Cade. Sections 25505.2553 536. 1 undemsnd tho if the
build murnsn0y haviceanun6th my mpondbiliry mnmify dm «cup
11 art mmla wlilClMIlQ6Jle arm lsaYanCC OfaCMdlV'al[MOCCapan
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Job Description
NIC
El
Valuation
'4'j/y4
Re -roofs
Type of Roof
All roofs shall be inspected prior to at
installed. If a roof is Installed without
I aeree grove all new materialerfb
Signature of Applicant
OFFICE
all non
aofing material being
I -obtaining an inspection
spection. Applicant
point source regulations.
4/ 0 0
Date
All roof coverings to be Class `B" or better