01110056 ERTINO
CI BUILLDIN DI ISiONPERMIT CONTRACTOR INFORMATION:
'
BUILDING ADDRESS: PERMIT NO.
11020 NORTHSKY SQ A B S HEATING & AIR CONE 01110056
VN'ER*S NAME: APPLICgION S B DATE
KOSTANT SUSAN G 334 SHAMROCK DR 11/ 13/2001
t'HONT:: SANITARY NO. CONTROL NO.
1 (408) 238-7178
O O O ARCIi1TF,C MNIGINCER: BUILDING PERMIT INFO
m- BLDG ELECT PLUMB MCCH
N< IJ 1-1 L. -I L_J
LICF-NSED CONTRACTOR'S DECLARATION
5 Job Description
I he
alum that I am licensed under provisions yf Chapmr 9lcommencing REPLACE FURNACE E.
rn
1-ad with Section 7000)of Division 3 of he Bmincssxnd l'mfessiom Cale.and my license
in GJl Taco n J e
o L U License Claes___�`�11 t� Lic.p
Dam LI ha•f)1 CymontE
3 a lo ARCHITECT'S DF-CLARATI N
RC
!RCC Id uPnmdefmnm —1'hMQuNic retards
OWNERBUILDER DECLARATION
v`= 1 hereby.Blum thstI.. the
in am exempt from,nus the Cynoou Craft
t Anne Law fm.ty
r z M following reason.(Section]o3L5.Business and Professions Code:Any city or county $1300
E O whim require a permit m conuru<t,al¢r,improve.demolish,or repair Lay>waurc
ad
t its issuance.alw rtquircelhe applicant for such permiun nleu signed sat¢mem - __ _ _ __-__.___ _ __ ___
- ti;a�it�nli«n.eapamaanttamevmvi�anxormecantm<ta„ueen.eww(cnapter9 yy,,��,�,r.AA,. ., , ,.. . Valuation
or hot hncing whh Saerefin ri andtDivision far
hM Bmircu at Mian. n,vi -t ;'3�� ��0'9 •v (�
or that he is exempt therefrom inJ the basis for the a11egN<xemption.Any violation - '
-of Section iv any applicant fora permit subjey¢the opplicam m a civil'penahy'
of not myrt;ban pn.n one nynarta spoors($snB). 301°tPN 1`14OLD@H PLUMBIN ' '' Occupancy Type
°L as owner at the property.or my employees with wages aatheir sole compensation, 303 ROUGH MECHANI AL
will do the work,and the structure is not intended or nfrered for sale(See.7844, 3 0 4 - ROUGH EIiF_Lfu'&�iI1] ):c[ions'
Business and Professis en onCade:The Contractor's License Law does not apply to
owner property Wbo builds or improves thereon,and who does such work himself 505 - FINAL ELECTRICAL
or through his own employee,provided id that such boner,is of arc not intended or
drooled for ale.IL howava,the h him h - tis old he din one'cur of - - -- - FINAL
g ar impryvetmev r - 507 = ...PliUMBING-
oprovefonetbetsme of add.).win hone the M1umen of proving that he did not hood or 508 - FINAL MECHANICAL
improve purlwu y
col.asowner othe p m exclusively p
t F withlicensed contractors
conatract the ( an 704, Btradcss and ProfessionsCodc:)The Contractor
ad who confials.for-inch projects with touors)licensed pm m theLicense Law t owner builds p th
._ _.
Contract Limme Low.
❑lam exempt under See. � ' ,B&PC for this movedI; :.t`I`
Dere
WORKER'S COMPENSATION DECLARATION
I hemhy affirm under penalty of perjury one oL the following declarations: J O/
° 1 have and will maintain a Canificam of Con.\ant to self-insum for Worker's
Compensation, as provided for by Section 37W of the Labor Code, for the
_ performance of the work for which this permit is issued..
ki have and will rwtotal.Worker's Compensation Ins unnee,as required by Section
37W of the Labor Code,for the performance of the work for which this permit is
” issu<d, y Wo s/Compensation Insurance canner cand Policy number art:r �,t
Came- �..VT { fI. olicY No.: W J'�V
.� ,, '•.�1li r' ry t �. .' d•r
CERTIF CATION OF E EMPTION FROMWORKERS';
'! COMPENSATION INSURANCE.
r' I("is:eciio,a raid!not M completed if the permit is for one hundred dollars s f,' r '•
($1001 or less.)
1 terry that in the performance of the work for w ide su is permit a issued,I
shall nen employ my of
in any manner zy as m become.w5)ect m;the Workers'
Compcnzation Lars of CaliforniaColifi .Data '
Applicant.' i
'NOTICE TO APPLhe Work If.Compensation
sari this Certin%of of Exemption you.mould
become Z forthwith comply vain such Provisions or iisprovinhall IOewM1or Code,you must
comply Lal Provisions or this permit snarl M1e deemed mvykeA. -
"" "' I - •CONSTRUCTION LENDING AGENCY -
�'' I hereby Blinn that there is e'conswction lending agency for the pcdirrmance
ora r o!the work for x hich this permit is issu<J"ISt.c 3097.•.'...iv,CJ ... _._
_
Q Lenders Name. .. C _,_.__._. •.. _ __ ...
Lender's Address
U 1 certify that 1 have mad this application and spate that the above information is
frr`F•I eomtl.I agree to comply with ail city and county,ordinances and spate laws relating
Q V
to building t toss dhereby thatrepresentatives ofthis city to nmrupon
ti �] the alio t ed Property f pectum purposes
a owe)agree to save:indemnify pe and keep harmless the C ty of Cuperi no oge ad
I0 habill judgment,c t d expenses Inch may'n any y a<me eF!ns paid
U\,Z Cty q ce ofthe gram 9g of this pc d
50 CI NT U STAND' WILL COMPLY N/�ALL -Po1nT` Issued by: r Dale
Signature of Applican onuxpo/" 3 .Da¢ Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
. . wain Ippneamormmrebdlangaceapantstoreorhandlehanmimearial . ..Type.ofRoof .
ss d f d bydn C pen M la al Cate Chapter 9.12.end the Health and Safety w- - . ., f i - �•.. . -
Cade ❑Y.-ection 255PIO No l._ rin r. '\ hath r t
_r.;,. - ,,.. _ .T.: -. . All roofs shall be inspected prior to.any roofing.material being installed.--
Wit
nstalled. - _ -. ..-
Wlltheapplicanto f re W ldmg pa equip t a ea which If a roof is installed without first obtaining an inspection; Fagree to'remove
emir mountains onamm t fined by theBay Arca A Quality Management
District? \ all new materials for inspection..Applicant understands and will comply with .
I` °Y i r RN all non-point source regulations: ,-
4 I have read the W;aidous materials requirements under Chapmr 6.95 of Ne - r
Calif rod HeabB&Safety C&le,Sections 25505.25533 and 25534.1 understand that -
ifthebuildingdoes not currently have eananethat it is my responsibility to notify the
decuryam of the requirements whityI�us be mei prior m Issuance of a Cenincam of
ti apy¢r. n( D
Signature,of Applicant - ate
Dxnery MIadaed tNo Date All roof coverings to be Class "B" or better
y
• _ - OFFICE