02060178 CITY DIIVIISSIIOMNO
BUILDING CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10851 NORTHOAK SQ ATLAS HEATING 02060178
OWNER'S NAME: APPLICATION SUB DATE
BERTRAM J S TRUSTEE 155 SAN LAZARO AVE 06/26/2002
InPHONE: (408) 739-0516 SANITARY NO. CONTROL NO.
° /°O ARCHITECTNGINEER: BUILDING PERMIT INFO
w C BLDG ELECT PLUMB MECH
wa l_7 CJ I" 'l J
LICENSED CONTRACTOR'S DECLARATION
O 5 y z 1 hereby affirm that I am licensed under f Chapter 9(cnmmenem Job Description
°i—o provisionse REPLACE FURNACE & A/C.
emFw with Scniorce ad of xion7of the Business and Pmf ❑m littnx
y m f J is in full forte and c l! �s� e, n y
w0 a U Liccnse Cl ss Lic.M
Dam 1 Convector
3 w Ii+ ARCHITECT'S DECLARATION
C CS
a.a; I undersmod Ino plans shall he used as public record,
sir
E:p O Licensed Professional
o� OWNER-BUILDER mDECLARATION
I hereby affirm the 1 1. exempt from the Contractor's License city
o for the
follow!'?< which inn reason.(Section 7031.5.Business and ve di,uml h,m Any city ar county $3000
which its Issuance
eealso m turewcL ober,improve,demolish,a repair any svupum.
to 5: vires the trap for such mn's Li ose (Chamrnl
Prior to its issuance.also my app pcsigned
Nat hmi5,lirencd purpureum the provisions of drc Conuactols Liccnse Law(Chapter 9 Valuation
(core erein witn Sea,..700h)of Division J of the Entinas and Vnimssion[Cade A-""T'31 Igr1t0 pOl e„�'3T,p Ts•� 'p+ ysY
or that he Is exempt therefrom and the hams for the alleged ciemjtion.Any violation t,�'''-a Y' ` •1..+ ^1 s .L...
-of Section 7031.5 by any applicant for a permit subjee„the applicant o a civil penalty
of not mom than me hundred dollar.(ssBO) 3 0 3APN �r= MECHANI AL ” ' ' ' Occupancy Type
❑I,as..or of the pmpry,or an,employes with wages retheir sole compensation, ELECTRI AT,
will do the work,and the ameame'is of intended or offered for sale(Sec.JOSS, - - - --
Saville.and Pmresdons Code:The Cnntmanrs License Law does nm apply to an 505 — FINAL EIi '�'RI'iR(I11Al3ections
.am,of property Who builds or improves thereon.and who does such work himself 508 — FINAL MECHANICAL
or through his own employees.provided that such improv encs am not intended or
m
'-drrned for sale.u,however, building is sold witnin and _ r
garen(4poyearo
omplction,purpose
posecournia-builder will non the Horden of proving mat rte aid no,hila or .
improv[for wrpaxe arcate.).
_ O 1.as owner of the n exclusively contracting � " ' - - '" '- '- •'. .... _. . ......'.. .._.__ .
prop. yam enc y con g Profession, div)Th Cmdrtors's - -- -
conswa the loosen(sm. toll,Busies and enywhbCode:)The Co thereon,
License law dan not apply man owner of a coihy who builds se improves thereon, r
and who m License
for.such Prolects,wirh a commemgs7 licensed pursuant to the. .. .... ... .... . ..._. .. _ __. .. .- . . _ .. .. . .....
Convanoln Liccntt L,w,
❑l oro exempt under Sec .B&PC for this«awn
Owner ' Dam r Let)
do WORKER'S COMPENSATION DECLARATION JU)_
O
I hereby a8iren under penalty of pejury one of the following declarations 2002
i• ❑ 1 have and will maintain a Cenilicae of Consent to self insure for Worker's BU'
Compensation, as provided for by Section 37M of the Labor Code, for the L.1)11/G
pirfomtance of the work for which this permit is issued. ff..//II�I�Vr
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
7
]Iq of the Latan Code for the performance of them work for which this pert
numad M ark[/.sC p s ion1 sura cec and Policy no the nrc.
Cattle O / �s ti i��1v til. r) ..r ..
a„ CERTIFICATION O EXEMPTION FROM WORKERS' .. 'i I e•. a r'I
COMPENSATION INSURANCE' "
(This section need not be completed if the permit is for one hundred dollars r
IS 100)m I...l
<empl that in the performance any ro of mthe work for which this object
t e Worker 1
sol pins employ any person in any manner co as m resume suM1l<et m the Worker, r
Compensation law.[of Cnlili,mia.Wm
Applicant 11
NOTICE 9O APPLICANT:If,re aper making thisovisio s of ar .Labor io d you ehoulst
becomesubjectcomp m the Worker's eman,s thin provisions of the Imhof Code,you mon
Q � fnnhwim comply with such provisions or this permit shall be decreed r<voked. '
�'� •+• CONSTRUCTION LENDING AGENCY
a > 1 hereby after thai there is a construction lending agency for the Performance
of the work for which this permit is issued(Sec.309].Civ.CJ
p, Lender's Name... _.. _.. .__. _ .. .. _ _. .... ... ...... ._
G z Link,.s Address -
C.) I certify than I have read thin city
Had
ion ntd swm th:u the above law,
relon
cones 1 acme to comply with all city and compo ordinances and nate laws relating
to building construction,and.!,Rwhereby amhorim«prcecmmives of this city'menmruprn
the ahn(Wl)same
a oto pro yhniyand onpnposs
F y• (W'Fucroumd ni .InJ.mriilY and keep harmless the Co,o(Cupery'no againn
Vi With 'ni 't�:lppmen cosec aM expenus which may in any xny seem got t said
V.Z Cir c qu of the'nntingprlhlspermit.
Dvlf.. B�Tro;lxAND ^aLr .MPLVWITrI y,jemT Issued by: lir Dale `- ('Z�
j elf
coli pphranvcammnmr nate Re-roofs
., IIAURDOUS MATERIALS DISCLOSURE
w5 n j+puca a future holding occupant start or n,nme na:atdau,mate'al . . Type of Roof -
. df ye capon ut pal Cole Chapter and Hearnande fry - '-.._ ... .. - - .. ...
w1e S ao 25532IaI ..r.. s• i y ••
Yes+ — All.roofs shall be.inspected prior to any_roofing material being.instal led._
Will the applies t o,future building cecupa t use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emith J Tran t as defined byme Bal A,reyr.(,r Qualty Manage .nt
• Din ct all new materials for inspection. Applicant understands and will comply with .
°Y' -L;1`Q_ all'non-point source regulations.
I'hive mal the hxaa materials re,mmotems ander Chapter . 5 of the
Califomie Health&Sato e.Sections 25505.255)3 and 25534.1u ennnd that
ifine buildin8 as not _mly have a tenant.mat it is my rt�Po sib' yto nmi ythe - - - - -
Inkvpum of e m - cots which muslK any< a Ccnif me of
Q /K®
Signature of Applicant Dale
Ox ser Int t d scam • Dme All roof coverings to be Class `-B" or better
.. .. _ ... . . .. OFFICE -..