NO PERMIT NUMBER BUILDING ADDRESS'. vv v lava
SANITARY NO. APPLICATION SUBMITTAL DATE
UWi NAMEI)IWMI 710 4/
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ARCHITECDENGINHER S/D 1283— BULIIINO PBRMIT INFO `" "?•
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z N_ LICENSED CONTRACTOR'S DECLARATION
Thereby affirm thin lam licensed under provisions of Chapter 9(commencing Job Description
a—t, withsectimi7m.rDivision3.ftMBunnessand Professiora Cade mY licenser -
!L x w u to full force and f 2
Licmae Clau Lic N
Date Cie
O J ARCHITECTS DECLARATION
✓�y 5. I understand my plans shelf be used as public records
i i O Licensed Professional
w OWNER-BUILDER DECLARATION
C 3 I hereby aRnn that 1 am exempt from the Convenor's Licensor Law for the
S x O following reams(Section 7031.5.Business and Profeniom Code:Any city m county
i3 x which calcines a permit b Construct slur,improve,demolish,or¢pair my ammum, Sq. Ft. Floor Area Valuation
prion.its issuance,also repines the applmi m for such partial to file a signedslaterrom
Bad he is firemen]pursuam to Ne pcovivons.f rhe Contractors Licenu taw(Chapter 9
(commencing with Section 7000)of Divisom3 ofthe Business and Pmfessiom Code)m ApN NumbOType,
that he is exempt therefrom and da bash for the ' / er Occupancy alleged exemption.Any violation of Y YP .
Section 7031.5 by any applicant for a perms subjects the applicant to a civil pu sly of
pt mon Nm five hundred dollars(S500).
Lasnwnnarthepropemr.armremwoyaawithw.geaaeNei.snlemmpennsdou. Required Inspections
will Professions
r fie woh,and the a Cont is trot inanded m Law
do for or apply so an,owner of
and property
who
Code:The Contractors Liunu law docs rot apply tom owner
progeny who builds or improves election.epwho does such woh deed or or through
dfor
his own employees,Provided that such improvements sold art not immndnd m.Snail for '
side , en of pr via in sold within oneymofc.mple for doe
net-W iter will have the burden of proving raat be did nm Wild or improve for par-
pose of sale.).
❑Lee owner of the Sm.7 y,.B ealus and corrosion,with:)The
mnvsnors w
cr.Let the project p x.o an c Business and Professions ds m u The Conmecror's ind
carer taw does nm reply to ts owner ns progeny who Wilda rs improves thereon,aha
who contracts Law.for such projau with a convacmrts)licensed Pursuant Ne Convutara
I-)I so law. (/
1 ern exemp undo Sr,,. .B&P C for this sedon
v
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirmunder pmmy of Perim,ora,of the fallowing declamations:
C1 I bevc aM will mainnln a Cenifine of Conaenuo ulf-insum for WorkeesComm.-
sation,m provided for by Section 3700 of the LOW,Cade,for the performance of the
wu��r=
which this permit is issued.
pyin.veand will m.mmin w.hera Compensation maaranm,n referred by Section
3100 of the labor Code,for Ne pefmmantt of the work for which Nis permit is issued.
My Woes Ca lion l me came"and Palmy yin art
Amer: (.MP SO IJe Policy N..:L' k�YY)In L4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scOmn m ed nm is completed if the permit I,Intone hundred dollars(SI W) s
of less.) -
I cre iy duet in the pe fmo arae Mme work for which this p mon is ismed,1641
not employ any Freiman my remise,so ss m become mbjxt to the wakenCompen-
sation Laws of Cdifomu.Dam
Applicant
NOTICE TO APPLICANT''.If,after making this CcNficam of Exemption,you should
hecome,subjml to Ne Worker's Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this permit shell be deemed rooked.
CONSTRUCTION LENDING AGENCY
Q I hereby affirm Wt dma is a mnurvcuon lending agency for the p oformmce of
r ^ Ne work for which this permit is naucd(Sec.3097,Civ.C,)
Lenders Name
[� 7 Landers Address
W G I ttnify than 1 have read this application and sive ram the above information is
Aa z comet'.1 ague to comply with all city and county ordirunea and sum laws aiming to
building conswcuon.and hereby mthmom ro,mommaivesof this city to enmr upon rhe
U O
eWvepariumned o,"y fmnimi,lorm purposes.
W t.. (We).,or m save,indcmndy and kap heresies,the City of c,smino against
C f,, bablthics,,whorsms.casB and expenses which may in An,wsyxcmeagainv said City
�. 14 to cmac9eence.f lbs g.an,of this proof. '
r In APPLICANT UNDERSTANDS D WILI,COMPLY WITH ALL NON-POINT
V Z SOURCP,REGUTA'IONS. Z//
Signature of Appli U u mem
RDOUS MATERIALS DISCLOSURE
Will the.,,.am r future Wilding occupant store or handle hamrdous maenad Re-roofs
as defned by the Cu mo Municipal Code,Chapter 9.12,and the Heath and Safety
Cndasxhoss, s532md? /� Type of Roof
0Y. .tGJNo '
Will the.ppbrmr or forme Wilding xrapmt use emolument or devmea whis
mdouanu m fir
t All roofs shall be inspected prior to any roofing material being
has air cnoticandefined by the But Area Air Quality Management installed. If a roof is Installed without st obtaining an inspection
p1ivfe7mit I a gee to remove all new.materials for inspection. Applicant
❑Ycs g
I have sailro
me haea .as naris arelninmem,ander Chapter 6,95 of the Cali. understands and will comply with all non point source regulations.
tomo Health A,Safety Code.Sections 25505,25533 and 2553x.1 understand that if the
building does nm
cu.II 'c n meant,
ant,thit is my responsibility
ponsiily o mud,flat occultism '
O
ofdmrea,am ulbenmprorroismneeofaCtote fO upnry.
z- Signatur o Applicant Date
Owner or euth � egem Dec
All roof coverings to be Class"B"or better
OFFICE