00030125 (2) CITY OF CUPER'rINO -
CONTRAC DR4NFORMATION"x A
HUILDINC DIVISION PERMIT �, ,,� ,�, �,, ,> ��' h
P y
BGamlvc nooRFss: ATLAS HEATING WE
PERMIT ISSUE 1900 3 0 12 5
OWNER'S NAME: 155 SAN. LAZARO AVE'
P SANITARY NO. 21 0®I"NO.
(408) 739-0516
BUILDING PERMTT INFO
A0.CHITCCT/ENGINCER: BLDG ELECT PLUMB MECH
0LICENSEDCONIAACfOR'S DECLARATION Job Description
p 1 hemby affirm that 1 am licensed under Provisions of CTap¢r 9(Commencing
Ky with Section]OW)of Division Sof NC Business and Professions Code.and my license is
in fell fame and error, a<.g REPLACE FURNACE AND ADD A/C
Z LiccnseClas
p Dam Connector
W7 ARCHT1EC15 DECLARATION
6 I mgeRuod my plans shall be recd as public mends
Licensed Pro,casinnal
OW NER-BUILDER DECLARATION
E I hamby air,,. m the rm that 1 am exempt forConnectors License Law for the
i O following reason.(Section 1031.5.Business and Pmfasions Code:Any city or county
5 which r .I.•P-11 m emtswe,ether.improve,demolish.or rtpran W.,tum
prior oitsissuancc,Alw"Om.the applicant for such Permit to fit a signed.....roan. S Ft.Floor Area Valuation
c< that he is licensi Pursuant to the Proviaiom of On Connector's License how(Chapter 9 9• $4500
=$ (eommencingwith Swtirn]ODO)nf DivbionJnf the Buximss and Profusinm Code)or
t Nn W is exempt therefrom and the basis for the Alleged ewmaw.Any violation of AAa�n wpi Occupancy Type
Section 7031.5 by any APPOELOt for•Pow"I subjects the applicant a civil Penalty of J G O NSlt�be[• 0 O .
not mom than five hundred dollen(S50Uk j�(�GJ 1 U 9
p I,As owner ofthe pmpcny,or my.wpIC,.with wa,,,As their wit compensation,
will do the work.end the..mmum boot intended or aBcred for .I.(Sec.1044.Business 204 - UNDER 0�I� S
And proermfah huila�'i vvestwmwr. a hod sweli=Lave a,mkhiout nessiforNwughhis 301 - ROUGH PLUMBING
own employes,provided that such Improvements art notimmnded m.Rued for sole.if,
however,the Wilding^rimprovement is old widtinoneyear w –
of
mpletion,theOwner. 303 ROUGH MECHANICAL
builder will hove DEC burden of proving that he did not Wild or improve for W'p^w Of 304 – ROUGH ELECTRICAL
ale'). 505 - FINAL ELECTRICAL
p 1,as owner of the property.em exclusively contracting with licensed comrwme m
construct the project(Sec.7044.Business and ProfessorsCode:)The Contractor's U 507 - FINAL PLUMBING
cense law does not apply to an owner of property who Wilds or improves deemon.ad, SOS – FINAL MECHANICAL
who contracts for such projects wish a canvw.or(s)licensed pueuwr to the Correctors
License Law. ,B&PCfw this moon 514 - FINAL PUBLIC WORKS
Alam exempt rndersw. 518 - WATER HEATER
Dam
WG,,.,COMPENSATION DECLARATION
11 hereby anion under penalty of perjury oro of the following declarauma
Ase end will mabus n e Certificate ofCouca m elf-insurt for Wmse,'a Compo.
ton,ss provided for by Section 3700 of the ISWr Code.BE the Performance of the
work for which this Permit is issued-
[-]1 have and will maintain Workers Compe...Be-❑tsuence,As required by Section
3700of the Labor Code.for the Performance of the work for which this Permit Is Issued.
My Workers Compensation Insurance arrive end Policy number art:
Cartier. Polity No.:
CERTIFICATE OF EKEMPOON FROM WORKERS'
COMPENSATION INSURANCE MAy .01200
(This we0n wed not W completed if the permit is for mm hundred dullan(SIM)
m less.)
1.,it,But in the performance of the work for which this Permit is issued,l Nell not
employs,pcmon loan,mannerw s to We.,wbjcCIo.WWerkerYCompeosa0n^ U1• I)wG
Laws of California.Dam B L
Applicant
NOTICE TO APPLICANT:If.after making this CcniBate of Exccoloon,you should
become subject Or the Worker's Compensation provisions of the Labor Code,you must
Z forthwithComply with such provisions or this Permit shall Inc deemed mvnked.
L- CONSTRUCTION LENDING AGENCY
H Ihemby affirm that then its comwcuon lending Agency for the performance of
0'> the work for which this permit Is issued(Sec.3097,Civ.C.)
W Q U ties's Name
d Lendw's Address
C) 1 ttnify Nn 1 have rod Waapplication aha sum the the above Informetirn is
(–' entree,)agm to comply with all city And county ordinances end lute laws neleting w
rJU
building
(wo)ageeto,and
e.Inde nify End representatives harmliss the OilCityOf
ml upon the
0U aWvementioned property for iespecuan purposeL
(wc)egmc to save.indemnify and keep harmless the City of Cupcnino against
a. liabilities,judgments.costs and expenses which may In eby way a[rnm against rid Ciny
V ti APPLICANT UNDERSTANDS AI. sm . fhe ,acting of tND WILL COMPLY WITH ALL NON-POINT Issued by:l famnot. Dale
SOURCE REGULATIONS.
Re-roofs
Signature mf ApplicantlConuwmf Dae Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
W01 the applicant or future building occupant go-or Icoulk haas rdi material
As dcOned by the CoNnom Municipal Code,Chapter 9.11,and.be Health And Safety
odc.Section 25531(.)7 All roofs shall be inspected prior to any roofing material being installed.
p Yea ON. If a roof is installed without first obtaining an inspection,I agree to remove
(14Will the applicant or future Wilding ocC.Wnt sew e,uipmcnl w devices which
1_ all new materials for inspection.
J ,:haurdoos air contaminants as defined by the Bay Area Air Qualit Management
L�,uj..�mx
Yes pNo
avestal the haardausmsherialirtyvimments underChaPwr G95of the Califon
dc Safety Cad-,Sections35505,25573and25534.1un&c Card notation,Wilding
urrently have a henw,that it is my mspomibiliny m nnuly the owupant M the Date
which must be mm prior m issuance of a Compute of Occupancy. Signature Of Applicant
All roof coverings to be Class"B"or better
authorized agent Date