02060061 CI.BUILDINGD DIVISION
PERTNO
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
10652 N BLANEY AV ATLAS HEATING 02060061
OWNER'S NAME: APPLICATION SUB DATE
WHERRY NIARVIN D 155 SAN LAZARO AVE 06/11/2002
PHONE: (408) 739-0516 SANITARY NO. CONTROL NO,
O O ARCHITEC 'ENGINEER: BUILDING PERMIT INFO
w C BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
- v- 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
?� 5 with Section 2lw(d)ofDivision 3othe Business and tre:.inna ndLan Uri,...e REPLACE FURNACE & ADD A/C
m g is In full force and off _
•a,m U Licrn re CI ss Lic.M
i 0 LL H Dae Irnvaclor
ARCHITECT'S DECLARATION
I under and my plans shall be used as public retards
I S p z Licensed Professional
OWNER-BUILDER DECLARATION
u. 1'hemby affirm that 1 am exempt from the Contractor's License Law for the
z< following reason.(Section 7031.5.Business and Professions Code:Any city or county
F which requires a Permit m construct,der.improve,demolish,or epan w
any sctme $3000
so prior to its ssuN<C also req Rs the applicant fofsuch Permit to fl signed statement ._ _... ......
a. that he I'ce .edpursuant t the provisionsoftheContracmrsUi Law(Chapter 9 l g r a,.,• 4 .,, Valuation
(con g with5 t 700(1) fDivision 3ofthe Business dprofessions Code) (,s.'tt ( e31,�'4 ,( ;��.x. �LL.3 I'-��
or that he is exempt therefrom and the basis for due alleged animation,Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty'
of ant more man five muchad dollar.($50o), 3 0 3d'PN MECHANI AL It Occupancy Type
sol,as owner of the pmpcny,or my employees with wages as their sole compensation, _
will do the work;and the summore is not intended or offered for sale(Sec.7066,
R 01 IGH ELECTRT AT,
Business and Pmfaxsions Code:The Cootmetors License Law doe:mot apply to or 505 — FINAL E]BEGS(I F11@$pkPtions
or hoorrn hisow� builds
rm�dthat sruch iimrovementssare act work himself
508 — FINAL MECHANICAL
g employees.Provo PC
compile fon sale If,however:the Wilding or imen of proving
n sold within not year of - - - - -- - -
improveforthepose Falx.).ldea will have the burden of pursing that he did not build or
improve for purpose oLsaleJ.
❑Las lith p pony velY t t gwith l< d v maseconstruct the parjecd(Sec.0064 Brojimss and Professions Codep The Contractor s
License Low e t apply1 ne of opcnywho build r murproves them.., NINA d h nus os f t re
such projects with a co t s)licensed pursuant pursuant tohe
Canonici.,x License Law.. - _ -- - t
❑lam exempt unecr Sec. ' B&P C for his reason - .... .
Owner Date , � 0 2 Z�aZ
WORKER'S COMPENSATION DECLARATION
I hereby affirm unecr penalty of pciury one of the following declarations: BUILDING
L{� ❑ 1 have and will maintain a Cenificam of Consent to self-insure for Worker's G
•"N.� Compensation, as provided for by Section 37W of the Labor Code, for the
performance of the work far which this permit is issued.
❑1 have and Jill maintain Worker's Compensation Insurance,as requimd by Section
37W of the Labor Code.for the performance of the work for which hl.v permit is
"sued M Wor 's Com nsauonus�u'�r�1a(yJ{ Brand Pdlic numb/bei e
Car cr�l 'YoI2yN T - .__ -...... -
CERTI ON OF EKENIION FROM WORKERS' �'.t a` 1 e.. i 1 k�ti. .,
r .. COMPENSATION INSURANCE s ..
(Ths section need not be h
d if l
core etethe -----
(S100)or less.) p Dermic is for one hundred dollars
I n fy thin in the pc f 4munce of the "k for which thiilemrr is sstled,l
shall mot employ any Anson in any manner so ss m beEome.object to the Workers' `•
Compensation Lads of Califhmia.Dam'
Applicant
NOTICE TO APPLICANT:If,alar making this Cenifcam of Exemption,you should
became subject mite Workers Compensation provisions'of the labor Coda you mail
Q fnnbwih comply with such provisions or his Famor shall be deemed revoked.
Z _ .. ... .. ... . ... _ -. _ _ _
CONSTRUCTION LENDING AGENCY
tYi-7 Y hereby affirm that them is'a cnnswaion lending agency for the perOrmma
nce
�.0 of thework for which his permit is issued(Sec.3097,Civ.C.)
-Lnder's Namc._ ._..�.._ ...:. _...
Leeer
nd 's Addie""
U.8' i 1 cenify mat 1 have read this application and state that the above informancor is -
fat'F.t
Contact.1 agree to comply with all city and county ordinances and state laws relating
C C.7 to building con.stiction,and herebyamhorizc representatives ormis,rhytoenmfupon
>y W Jthe ffiove-mentioned property for inspection puryo s..
�_16 (Waliigrcesave,indemnify and keep harmless the City of rti
Cupeno against
VI)
It.
VI) m es,judgmems,cests and ex awhich may iry
I any way¢cae against said
�.).Z City in consequence of the gr ouin of is permit. ' . • _' f
APPLICA' UNDERSTANO A LL COMPLY WITH ALL NONPOI
U - tcUL I N ' 1 t
Issued by: Date
Sig arm prlir nm c meso One Re-roofs /
HA RDOUS ATERIALS DISCLOSURE -
Willtheapplican or future -liingcoNpam state orhandle hazareon"material —Type of Roof..
- a defncd by the Cupcn unlci Code.Chapter 9,12.and the Health and Safety
Code Section 255320 - I, •� ,'t .- ) :;t C4•x s x _...
❑Y All roofs shall,be,mspected-prior-to-any.any roofing material being installed.
W II IM1 applicant future building' pat .Baiequipment devicesewhich- If a roof is installed without first obtaining an inspection, I agree to remove
emit h and a d by the B y Area Air Quality Management g p g
Diam`oY No all new materials for inspection. Applicant understands and will comply with
Dora t me
. ' I all non-point source regulations.
1 hioc Hum.the hazardous anderinds rip tmmcnts Linde Chapter 6.95 of the
Califome w"'h 'afny Code -1fons2550525533and25536.I undcnsumdthat
it the build gducs not currently acat nant.that it is an"clumambility onotify the
u m- the nquiremenu wl- must be met prior to is nee nificam of
O up ) )
Signature of Applicant Date _
Ow I mmormisedagwt " Data All roof coverings to be Class "B"or,better
:.. •,• _. _ -_-. OFFICE . . . . . -