TEMP POWERCity �l Lr:3tv.J
Building Safety Division
s� r
4
LrZ:or4 EC7 C C 1 rxet'b DECEAVEA I ION t 1 - 11 :ped �n7�r to ®a,r®� � �t Fiu em. 9 (cumnicricim5 mita ..tion :.
-1139u) .1 IJi V isi-r, :3 "l � 1103enA 33 eased PFUl slum Code, and Toy license is in rull farce and effete
Licenseclaass .rwo-, 7` 5y �w. _���; 11d251IB
-
a 41 Em i flereity aMnn Mat i am exempt ..-Inti r. n wtor'. . IorItic (See. Ip31.),
l3aastnesa Ana Pavlc sans End.: An, ell. or r_imij wn'u[ii mgvires as pcaeanaa w construct, anlzs r, improve, de87 olish, or repair any structure, Prior to Its
issuance, alssa retinues the applicant for such permit to f.e a sparse statement Mat sae or s e is kenseR pursuant to Me provisions or t e v ctur';
Liven -a La7 (Unr for v (v w®cl ;a.®1 bcwtr.®®.Aim .v$.ym.xl.m.3 ort45. mzina,53 mo rr6;3®.n®s ..) or RIF., he ur sn, is �T�cmpz flicrefrom
mad ffiz b is fir ffic a6pd exemption. any violation orSect€on 7031.5 by any applicant for a permit subjects Me apInicant to a civic penalty ornot
more Man side flunziretl Zlobars���arCilsl:
in 1, ..- u7mc® -1 the rrrcrtT, ora —.j CITMIvywo. ii --a
®thu-'T.010 aoc}FcAasssla4sa®, ll d. , work, aid ffSc structure is not intended or erffefed
fair sale (Seco 7044, Business d Professions Code: The Contractor's license Elw ones not apply to an owner drpropeny woo BuiRis or improves
triercon, t[ vvno aces such tvwrR nimserr up Bureau ar M.--wgh nin P near r u vI ocu, pse-;iRad Lnut acri e,aap ape a:ats out a itunde or
_m Ior 3.1, 1f, by ti,r, the b elai as oa i jp rec iiia as sold withina uric year of Crrrnt,letiranr the owner -builder %vill have the burden of proving
tnat He or sRe Alia not uhd or improve ror ucy purpose ertsare).
as I, oounv at Inc . pert,, am cv—,.tra.fln, ®atfr Iaucnsca u�aea clam to corm ct the Fp 'cct.(Scc. 7U44, 13ti- acsa -Aa lcasiaa a
Cade: The Contractor's License w does not apply to an owner of property who builds or improves thereon anu 44 @o contracts For siren projects
who a contraclorpiI licenses pursuant to ins Contractor's LicenseCaw.).
Date:Owner's Signature
VV 1t,MAS' CUIVIFENbA t l tN MCLARA I IUN l tip b., .11=8 a®aacr pri- alt,j oaf -i v ®nc aet tlac Iivllov in dccl t8ons,
to i have and %vill maintain a certificate of consent to self -insure for workers' compensation, as proviziell rear uy Section i i of ure "Por Cone, ter
(Re perrormance or me wom for w icn !iris poet ;s ®ssm®tt,
a I fiiv. aa—a Will m'..'.' a zi ur cr ,c�r pcaaaa`aaissea lean aeaaa , no rc ituTud By Scuti.n 37UU of the Labor Code, for the V.6ormance of the work for
w ich tRis permit is issueli. my wo ers' compensation insurance carrier t! pra,icy nu ver
iris r -Ac 1J i i m E miSr, I1-4Ur,1v1Iqg s r relic, N.. Z)43095DU
(This section heed not be completed ifthe permit its for one hundred dollars rS 1001 or less).
® i certiry urat in site perrormance or ine wor—K Ibr wgicfl this permit is issue , i s all not re—mar tv Deceive; , adcvt to
tile warkers, VV- .n�ntioi.1. s ulifo ia, used ii&4e alae rt 13fival buzu u 3ubjucr au tht yrs' compensation Frovisions of Section 3700 of
the Eaalsor Cade, i shrill l'o wi comply witu timse provisions,
unty 1112611 S r�ppll��m-0t'v l eo�tas
WARNING. FAILURE I U SECUKEwUKKERs'COmPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT N EMPLOYER
10 Calivin-4d t raryn i xr,,3,.Bti#1. CI y u- Fu -4r_3. wr. 171 fl, N 1`10-14 U i I1t1r73AJ U U51-LAK3 .rld ,F UU), 15'1. A jLJr l ION I U 1.FIC CU5 1
Ot- COMrENbAI ION, DAMAGEb A�� P vt E t -OK IN btCm a ME OF i Ht 0K COuE, IN I Ektb 1, & A t i UKNLY'S I -ELS.
CONSTRUCTION LENDING AGENCV I hereby affirm under penalty of pe ury that there is a construction lending agency for the performance
ru Inc %vorR ror ivnich arms permit is issuctl fz cc..arav i, Civic %.I:
tauhdw-r°s IN -Me Lcwad�r's ABOreire
APPLICANT'S SIGNATURE I certify that I have read this application and state that the above information is correct, r rupee to comply evith all
city ana county ommunces ! state amus relating to ouh0ing construction, nnZ1 nereny auuinriZe te. uw¢otate®.= of Me Eat, al =t-�-IV to .oto. -_FIMI
eansa p ZFVr!J ion in lion parpo5cm.
n 11AINNON a:rt.aNLALLL i rr261i
�ag-tea, at Ap aie:nt Print IN_Mc uric