02070157 CITY uOnme DPEROIIvO PERMITCONTRACTOR INFORMATION:
BLy�D2ING
05POPLAR GROVE SQ AAA FURNACE & AIR CONDITIC 70`62070157
°IMAqW MARY E AND DAVID F 1712 STONE AVE APPLICAr�"7y�S�/2002
1ONE (408) 293-4717 SANITARY NO. CONTROL NO.
0 O O ARCHITECL/ENGINEER: BUILDING PERMIT INFO
m u C BLDG ELECT PLUMB MECH
<i U C-1 L. J t_)
i
LICENSED CONITRACTOR'S DECLARATION
n d o 1tionhereby 7Defnnn taro I oro of he
under provisions of Chapter 9(commencing CHANGE FURNACE J&b 1 rlrLption
iN�jwith Section 7000)of Division Jorthc Busin�nnd Pmlessions Code.and my license
is in full forte and
s a License Class_ - Lic.p
O Btu Doe Conuano 1�
3 G ARCHITECTS RATI N
1 understand rep plans shall be used as pu be
records
' >Y
?o
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby.(Sero that 1 oro aurin from the Conions Ce License Law co ,he
Z fallowing revun.(Section 7031.5.Business and Professions Code:Any tiny or county $2600
wto o whichreq uiresa Dermic no construct.ahxr.improve,h'nodemolish, fieri repair any structure
3m .prim uo is mosnce,alumto rgs nWvisionatn for zuchpemuuoicense Law(Chapter
- -- -- - al
(commencing
eedsed Dursamn m the proiDivisi n 3 o Contractor eButtes License Law ons Code)
_
wdnsemmn70W eromiaian3anneaasmeg,paPgressiaeacWe ^3,g4&t3BIb�'f1?t4Aa, , Ly Valuation
i ._ ) ) `�1. t . .• .. _ i V._ _ t n•,1:. �,r'• ,
of Sm he is exempt,any applicant
and or basis it thesubjects
cts the icattexemption,Any violation
-of Section ID]f.5 by hundred
applicant fora permit subja¢the applicant,o n civil penalty,
-ar cwt more than Evt Wndrea aml.rs($som. 3011PN ;-n:t' Occupancy Type
❑I,asowncrofnhcpmpcny.mmyemployxawithwagesasnM1cirsolecompensa,tun. 303 - ROUGH MECHANICAL
will-do the work:'ad the structure is not intended or oRcred for sale"(Sec.761,1.
'Business and Pmfessions Code:The Comramr'I Liccnsc Low docs no,apply to an -5 U 11 rluuurl 11 Llolls ` "
owner of prolixity Who Wilds or improves,hereon,ertd who docs such work himself 505 - FINAL E
or through his onva employees.provided th i suchimprovxrocats am no,intended or
tofferod forstle.-Ira erthebuildingo p r sold within on.year of 507 FINAL "PLUMBING
bmplt to Wlde will M1 ,htaunden hedid.Wild., 508 - FINAL QAL��
repro f r rD.e orsale.).
LED.....
,
_. . . _ _... -_ _....._ E® ---------
...
01.ax owner of the,property,am exclusively contracting with licensed cars"cmrs to
consumer,he project(Sec.7000.Business and Professions Code:)The Contractors oL�di r l Al. .• ----
- License taw does no,apply,o an owner of property who Wilds or improves therean, -
and.who.comracusfor.such.projccu with a.commends).limmcd.pursuzonsts she _.. �.._. ___..___.___._..._. ._.__—_—___. .. _ .____ ______ ___ ____....._-__
D 11 p ....
- C.rxm,to,.LiccmcLsw. �� q02.
olemexempnundsr Sec. ' '` .'l.. 'BB P C for thisrt ' ^.lu'•:tu:''
DINGWORKER'S WORKER'S COMPENSATION DECLARATION
I hereby effort under penalty of perjury one of the following daluafiom:'
0 1 have and w01'moinuih a Cenikone of Conscm m self-insure for Worker's '
Competustion,as; provided for by Section 3700 of the Labor Code, for B®
peformance'of the work for which phis permit is issued.
01 hats add will mainmin Worker's Compensation Insurance,as required by Section
37M of the Lobor Code,for the performance of she xork for which this Permit is
issued My Worse?.Co pe seuan hviunntt c er sad Policy umber
: .. ...
12
51
pub
ern. IFl ATIO O .FXPam,
R (EI
COMPENSATION INSURANCE'•'„-
..
......
....I I
t - !this union need not be tomdc;cd Kim permit is for one hundred dollars
($10(yorlesc.) .
shsi Ic certify that pcin ymaofthe s.f come thispc txi.irke1 \: 1. v 1 �
all bol employ.,of Cidi in any manner se as..m Weome subject,o the Woekcis'
Compcnsa,lon Laws o(Califomia:! - '
NOTICETOAPPLICANT:If.after making this Cmificros of Exemption.you should'
Q 0 become come subjecto the Worker's Compensation provisions or the Labor Code;yoo mus,
foi,hwlNcomply with such provisions or this pemti,snail W deemed revoked.
CONSTRUCTION LENDING AGENCY.
I here aRrm that di o tion g
lendn7 e nc fo tine rfotmu ce'
of the k foeh h this pe I -issued(Sec 3097 O C.)
-Q Lend r N me /f
.7 z Lend Addrt
UC) - a
1 agree that I he h al pphcet d or i enc,h b !armor on is
f*x E•t �cdrrtn 1 ay to comply ,tit all tiny and county and nanca d state laws rchbng
D,U uoWldngconswd on antlhreby autbohm irprcuntalives of this city to enter upon
the eWven¢mm�ed Property for inspcmion purposes.,,_-,
r.y• Wel eg ,b ve:indemnifye dk ph mdess,he Giy o/Cop nino eje nn
:u!) liabilities,judgments,costs and expenses which may in any way¢true agvnn said
U City inconsequence of the granting of this permit..' /' CO
'A'PPLICA.NTUNDERSTANDSi,NDN'ILLCONlk:f A'r HAU: M
s u REG L A 1 �s Issued by: Date
ig„ Nrr,ora lib noco[rax . .D r Re-roofs
HAZARD US MATERIALS DISCLOSURE t `
•'
Will the applicant m fume building ompm,nae handle haisamus material Type of Roof - .. _ -. ...._ , ...__. _
4. as defttd by,h CUDenneo Mun o1 Code Chapter,911 and th Health d Safety "t ll II
Code Section 1553110 - - "` �l•.t.
ova
No All,roofs shall be inspected prior.to.any roofing material being installed.__. __..... .
win,ne DDlend,on t t"n coc P t se equipment devices which If a roof is installed'without first obtaining an inspection;I agree:to remove
Y Y Q i 8 ment
rbstnm all new materials for inspection. Applicant understands and wil_1 co_mply with
m t h stud us eu enmm nems deRned b the Ba Am.Air ualn Mena e
°Ya t n,f " r r all tion-point source regulations...,,, -
,r... I
bow,'
e elrtod the'Nurd s'mamnils¢gwrtments',under Chapter 6.95 oLNe
calif)roil He61th&Safety Code:Ssctiotn 15505;15533 and 15534.1 understand that
occupant
ccupant of 0rcesgmnarertuemessnllyNhhend.be rmn'tpndr.,4,Q assrcs7asnm/e�ofra jcesunfmzclfye
thoef
Ce` yli
Signature of Applicant i
Date
ow� seAll
roof coverings to be Class"B"or better
:I.
.., t,_r. , . .OFFICE"