00120107 (2) CITY OF DI IsION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERM]r NO.
11,63 STAFFORD DR WATER HEATERS ONLY 00120107
OWNER'S NAME. APPLICATION SUB DA'1H
CHU WEN N. AND THECI A M 5170 AIRPORT BI V 12/Il
41 PHONE. SAN[FARY NO. CONTROL NO.
(415)349-3747
n-Z ARCHITIic VENOINEER: BUILDING PERMIT INP)
tt m 2F BLUG ELECT PLUMB NIECH
6
>-Sy_? ntemny arc�oin li�,��r���d on. ���li.r��Ri cn��tereler,:nnteecing Job Description
QOy withSmlinn]INgB of DivisinnJnl the Bminessand professions Code,and my license
t J is In IJI I ce and effeel.
mez�a Liccnsc Claw Lic,p REPLACE 50 GAL WATER HEATER
a d Date Contnnnor
3 a vii ARCHI'111CI'S DECI'.ARANIN
t—y 1 undennmd
7=0
my plans nhnll be nxA ae pnhlie records
se
ar
i p O Licensed Proc,,m net
OWNIR-BUILDICII DIZCLARATION
I hereby alErm that 1 ren coat from the Contractor's License Law for the
F 6 6 hdlnwing mason.(Smuor'In31.5.Bneinenn ural Podc,,iom Code:Any city or aunty .
which mquircs a pemtit m construct.alter,impnrve,demolish,or repair any structure
i3m prim to its issuance.also mquires the applicant for such pmanitto rile assigned statement
roll h.to I mcmed pari.Bait,.the pinup.....nl me C„..oclor.Liam,Law fchaptm q Sq. Ft. Floor Area
(commencing with Section]IMP)of Division 3 of the pastures. and Professions Cale) Valuation
or that he i..es,mpt ducichnnt and me ba.i.e far the at cged exemptimt.Any.;nmaon $700
of Section 7031.5 by any applicant for a pemdt subjects the applicant to a Civil penehy
or not taws man live Ili ntall dollars lS.1mr- APN Number - Occupancy Type
01.an owner of the prat or my mnployees with wages as their wile compensation. ''In .I '4 1711A
will Ju the work.and tic a....nwc Is an Intcndul or ofl<ned fn seals Sec.7IA4,
Business and Protesdons Cotte:The Contractor's License Law docs not apply to an Required Inspections
awn,
r of propely Who holds or improve%thereon,and who does such work himmlf
sit
eredfrhieawnhowevel,t Wilding
that such erniissolsarm hinonendmm 50 — FINAL PLUMBING ENERGY
offered for sale.If.mtwailde the hnaanfl a i.nkn of n nt i,sold he did one year... X76 — GAS TEST
tnl,letn,n,m,nwner.nnBderwiil haws the naw,a m pot lag lna.he did not nails nr 5 -
ntpowefmpaflowa le.). 507 — FINAL PLUMBING
co I,n proje pmmnv,ore esdmissly.ommfssi with dc:)-FW Contractor..
mclrvd thurpms n (Sec.]III),amines and erty who h Ca1oJ The Contractor
Lice me Ltw dray not apply loan owner of prnpery who halide or Improvn thio the
and who contracts for projectssh projects wire a ttmtrunngc)licensedpunrm the
01 min tar's Liccnsc Sec.
❑1 am cxrntpt under Sec. .B h Y C for this rcanvt
Owncr Dat,
WORKER'S COMPENSATION DECLARATION
. 1 hereby.1inn under pewlty of redo,one of the hollowing declaration.,: F'NALED
❑ 1 have and will n.nmain a Certiacale of Consent at elDfmam tar Worker'.%
Corsa.Bons as provided for by Section 3]1X) of the Labor Code, for the
perlmntanuc oflhc work far whish this permil is iaxnN. MAY 5 q
EJI have and will mainain%rkcr:e Compcn.alinn Imuran,,,as mquircd by Sermon 0 `a [001
370()of the land Code.for the perforaciam of tic work tar.'hush ]it,Itcrimil is ,
issued.My Workers Compensation Insurance carrier and Policy number are:
Currier Policy Nr: BUILDING
CHRTIIaCAI[ON 01'EXEMPTION FROM WORKERS'
COMPHNSAI'ION INSURANCE
('ILis.secana r,cd nut Mcontplimd il'the pcnnit is l'or one trundled dolluta
(SIUI)nrlees)
1 realty IM1m in the performance of the work for which Ibis permit is issued,I
411111 not employ any person in any n r so as to becon a aobjem ,the Workers'
Contpen.cation Iatws al Caliarma.Date ms
Applicant
NOI'ICI?'IUAI'I'LICANrn Ili aro,naking this C....ficane nl Esc nptin r.you should
because subject the Walker's Compention previsions of the Inbar Coale,your m
u ust
O uufnnhwilh.omply sum 1,w.h pruvisiras to this permit ehail he dee rad revoked _
z
^F rte. CONS isa coNLENDI NG AGENCY
Qd 1 helico which this there is a unred(Sm. ImNi ng agency bn ilia perhnmvne,
Lithe work for which This pcnnit is issued(Sm.AN)],Civ.CI
L Lender'.Were
., z z fenticr's Address '
V 01 certify that I have mad la,applicatian and rune that the above ill —lion Is
k. r- correct.I.,me to comply with all city and county ordinances and late laws relating
Q V ,,hadding..........lion.and Ili mad hnve m,ow,tutivesnl'lhis city menlerurym
Iheabuvcmcntfoned prnpery for inspection pmrWses.
ray y (We)agree to save,iudcnaify mail keep harmless tie City of C..p,nino against
cn Iiahilitim,pd,nc.s.costs and np:nsec which may in any way accrue against.said
U Z City in cnnxyncncc of the granting of This permit.
r APPLICANT UNDERSTANDS AND WI LI.COM 1'I.Y WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
Signature ofnpplicam/Conttncmr Dam Re-foots
HAZARDOUS MAfER1A1 S DISCLOSURE
Will theappli,aalorfuturebuildingoccnpmm,lomnrhamneIt.,adin.ure"ivl Type ofRoof
. .
in,deaned by the Cmpcnmo Nkma pal Carl,Chapter 9.12,and the Health and Sali ty
Gale.Scmion 25532rpr .
Cl ye, 0N All rooks shall be inspected prior to any roofing material being installed.
Will the applicant or fdur:building.wcupmn use equiplocm or desk..which 11'a roof is installed without first obtaining an inspection, 1 agree to remove
nil h¢urdaun air contaninars as defined by the B.,Aram Air Quality Mm
anageent
ni.ldcr: all new materials for inspection. Applicant understands and will comply with
0w, ONo all non-point source regulations.
I have mad the havardous malcialk tequircmmmts under Chapter 6.95 of tic
Califant in Health k Safety civic.Sections 25505.25533 and 25534.1 undersand that
o the building does not currently have a lenlun,that',is my respo..vibility to noddy the
overprint of the regairerrems which most W mm prior to issuance of a Ceniricale of _
oampr...y. Signature of Applicant Date
Owner(it arthoniedagent Dale All roof coverings to be Class 'B" or better
OFFICE