00100016 (2) CITYOFDIVISION PERMIT
BUILDING PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
Is
OWNER'S tJAUIi: - - APPLICNI'[ON S ^1. t
f _
isiOmE: SANITARY NO.
GOO ARCHITECcENGINIiER: - BUILDING PERMIT INFO
• U -' - - try {LD ELECT PLUMB MCCII
>v
1 YS SOY'
CmZ Lmt EUC IRd under rDECLARATION .
Z iZ 1 hereby(dwf thin I am Iifib Bum6r,pmvBions of Chapter 9(commencing Job DesGrl On
p v_rku, with i eadd affect nJof the Hu: e. dPrnfesi mrCerde unci mylicenx
-1 u n full force unci cffcet s
ipu Lc Clxs .Lcp�p 0 ..
ova "" �� c r' TERMITE REPAIR " ;
F _ 3,ANCHifI.(:'I. I31 CLARATI(
y 9 1 understand my plans shall be asSdd ss public nvonls r r
i dc O Licensed Professional
LL`: OWNER-BUILDER DECLARATION
I hereby ff th he,I am dump.front the C adcu Lire.,Law for the
1=3< following reason.(Section 70.31.5.Business and Pinfessimal Code Any citycounty -
F'❑ whin requires itcc 't t n. t I. improve,d farepair ,sa Imre
aat3$ prat it, o re,tooldht,ap,hramfruhparmrt Rld a,r,redTtmam
III.'K, Ip t1 he p : IftlbContrarne,l 1 (Cnplery S FG Floor Area
(cold rg with Sect ]WB) fD' is E f the business and Prof a..ims Cale) q' - Valuation
or that he is uunrpi therefrom and the hasis for the alleged exemption.Any violation
of Section]031.5 by tiny applicant for a pearnit subjects the applicant y
o a civil penal. - _ -
ofnotmore thinfive hundred dollars(45W). APNNumberOccupankSy'SW
.°i a. f fl p pent ye pl Y ih g a:to pen notion, .
will d N k and the r t not intended ff "al for (Ser.9044, �r.` _
Bmrl P I ' Code I 1' C t l L'c n: 1 I t...lr lo., 342.4'20i�']Rel�( $d Inspections .•.
r of pmpery Win baild,or ho,does thereon,and who doas such work h msell `
or though his own employees.provided thus such impmvnnenu are not intended or - - -
offered for sale.III however.the building or Impmvemem is sold within one veer of
completion,the owner-builder will hate the burden of flowing that lie did not build or - 516 — FINAL BUILDING
improve for purpme of sale.). "
El 1.it,..pmr Ifth propend amexclusively contractingwll,licenical contractors to
,anaddratth p Ict(See 70-14,B n: dProfession,C I '1 Tire Contractor's
Cna,c Law dt apr,t aP ply who hijid,o,amproliald on - .
and h contracts
ors
t t: I' ,h proleprojects,projects,w 0 t t r(s)licensed m punuat r the
nm orelctsc
-
°lamexemptunderSec. ,I3&P C for this rens... r
Owner IJV¢
WORKER COMPENSATION DECLARATION
1 hereby affirm under petmtlty of perjtuy one of the fordwing declamtiotar:
I have and will n ormdin'a CFnificnm of Concent pr.sclGinsum for Worker's r �•
Compensation, as provided for by Section 31m1 of the'Lahnr Code, for me
performance of dm.ink for w!mb This pennil k issued. -
°1 have and will maintain Worker's Compdnsmion Insumnde,as required by Section
37M of the Whin Code,for the performance of the work for which this proof is ,
i.cmcd.My Wn er's Cn`mpensati°fin Insu1re�y/�e carrier and Policy nuhrber arc: ,
Car"W1',.�.fit ♦7 Wy Nn.: S r ^ nA f
CERTIFICATION 017 EXEMI'9'[ON FROM WORKERS'
COMPENSATION,INSURANCE
(This section necJ nm be complmeJ if the Permit is for one hundred dollars
ISlfp)or lest.)
1 certify that I I the performance of the work for which this permit is blued,1 s: '
shall not employ any 111.11 In any metope,so as to became abject to the Workers
Cnni,.,nlinI,Lnws of cahr�mlar Dam : -
Applicant I. .
NO]ICE TO APPLICANT:If,after making this Cerificale of Exemption,you should
z become subject to the Workers Compensation provakmi writhe Labor Code,you must
zQ forthwith comply with such providwasor this .it hall be deemcJ revoked. - -
E" .�., CONSTRUCTION LENDING AGENCY + s r
ai Iherehyuffirmthat there is a construction lending agency rot the performance ,
W of the work for which This permit Is Issued(Sem.30IC.Civ.C.)
I,etideds Nome
Z Iundcr'a Address
Lt.V O Icertifythat l have mad.his application and late that the at information is
t.. correct.I agree to comply with all city and county urdidamea,and stare laws relining -
- O V ro Mrilding constmcd°n,and hereby nthmird representatives ofnris city to enter upon
y W the above-men.innld Property for,inapenion purposes
F. to (W) g t ms indemnify and keep harmless the City t Cupen'no against
wn N liuhill c,] Ib t a Iand p :us wl h may Ia any wayarcane against sad -
U'z citym darter, < rrth y . g fads pI rite r `
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
S CE EGU ATI INS Issued by: Date - / ��Q O
Signmurer n Re-roofs - -
1 AZANDO r. I TEIHALS DISCLOS RE `
re apphram
or int dine..dcup nt store or in haim, ous ii rteduI Type of Roof
as def ned by the Ctmenino Mu cipul Code,Chapter 9 LI and the Heahh and Safety f t
Code.Section 25532(a)"' . • . .^ +. , .t
'- ❑Yet : Ll No 1 AII'rool's,shall be inspected prior to any roofing material being installed.
'Will the r,li, aorlumremildin,ecO,anrtweeyaipmelttordevice,which If a root'is installed Without first 'obtaining an ins ection, I agree to remove
mit hazardous air contaminants as defined by the Bay Area Air Quality Management P
vldc" all new materials.for inspection. Applicant undersiands and will comply with
oder °"° all non-point source regulations.
1 have read the h dcrdl m tcri els realuirementl hadder Chapter 6.95 of the
California fle.11II&Sdaly Cadd:Sordoad,25505.25533 I d25594 1-rd cteWtbm - '•
irlhe barld'mg Jos matelareollyha,ea Ouraftlandt,my reslnnih'fty mnoufythc
rz
cupam of the rcyuiremeno which olds.h.nmt pdnr
In is.om.of a CenifiOnte mf
Occupancy. - -
•r Signature of Applicant - Date
am .r pr,r, me - All roof coverings to be Class "B"or better
OFFICE