02060176 (2) CUPE
CITYOF BUILDING DIIVIISIONNO
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10987 NORTHSEAL SQ ATLAS HEATING 02060176
OWNER'S NAME: APPLICATION SUB DATE
DOYLE DOROTHY C 155 SAN LAZARO AVE 06/26/2002
PHONIC: SANITARY NO. CONTROL NO.
(408) 739-0516
08 ARCHITECOENGINEER: BUILDING PERMIT INFO
m❑ BLDG ELECT PLUMB MECH
a a f—D
LICENSED CONTRACTOR'S DECLARATION ,Job Description
C z y o I hereby affirm that I am liveried under providers of Chupas 9 mommenemg p
In,t: with Section?000)of Division 3oftheBusincsand ylmense REPLACE FURNACE/ADD A/C.
6 Y y] is in full force and
C ne 6 Liccore Cfrs Lic.N
dPofessi .Code.an
O a O Dam Contractor
a.I-i RCHITECT'5 DECLARATION
l:a ON S 1 understand my plans shall be used as public records
y y
m�i es o Licensed Professional
a s OWNER-exempt R m the Contractor
=a I hertby afEmm IM1at I am exempt from the Conuaaor's License law for the
F < following reason.(Swim,7031.5.Business and Profeasi°ns Codd:Any city sorority $4000
permit S x p which requires a la construct.altar,improve,demolish,or repair any swcmre"
or sea 3 w'_pnm tom aacc ale req stile PPlic ,f such per,tdtbfl geed statement _'hat be is 1'mn¢dpersuade othe provisions of the Contractors License La (Chapter9or Valuation
ao me g, m s air 7M) f Division 3 f the Bwjres. Rd Q efv oro,Coca) C't,}.N r',1..hbtp �;.:( i'lx;A"f�f
or that he Is exempt thercfmm and the ba.vis for the alltged cindpotaii.Any violation
-of Section 903 LS by any applicant for it permit objects the applicant to a civil penrlty,
of no,more than fire boosted did dr,(9500) 3 0 3 AEV I�bC64 MECHANIALr- ' Occupancy Type
°I,as owner of,W property,or my employees with wages as Meir sole compereatmn,
will do'the work,'and the structure'is nut intended or offered for sale(Sec.70W.- - - --- ----'-- - - - -
tf rslness and Professim,Code:The Contractors License Law does mot apply lm W 505 - FINAL EL DQAJwctions''• . . •.
owner of property Who builds or improves thereon,and who dress such work himself 508 - FINAL MECHANICAL
or through his own employees.provided thu such improvements arc not mounded or
a1fe7Ed forside.If.however;Ihm Wilding ..- - t i sold-withili one yearof -- .—_._.
'completion,the owner-builder will have te burden rof prmvi ng that he did not build or
improve for purpose of sale.).
I f,M1 propcoy ry
am cxcluscly correct,with I c licensed trwde,to ... •
° .
construct he project(S c 7044 B .'rte J Proftwurm,C J i)Th C tractors
Liverve Law does not apply to an owner offiroperty who builds pro a thereon,
dho. tracts fo such. ued pmt cwa.contructor(),I censed.pursuant toNe.
[I I am exempt der Contractor's c Fes B k P C for his outdo
Owner I `fire
- � WORKER s COMPENSATION DECLARATION nn O� rs
;"• 1 hereby of irn under fixedly of Perjury orie of the following declarations: Q� `00�
0 1 hive and will me nmin a Ccnificue of Consent to self-imme for Worker's '4O''V
Compensation, as provided for by Section 3700 of the Labor Code, for the
_ performaace of the work for which this permit is issued. y
` °I hale and will mdintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code for Ne performance of the-work for which this permit is
issued My /mu'<S �p .,n Insurance lane`r'�P P Lryle. �f
Carr 2' ( V pot cY No W V�r•V�I L� _.._ .... `..... r _.._...�.._._.._. ... ......,.> >. , �. . .._.._...._..._._
'hr.tC' TIFICATION OF EXEMPTION FROM WORKERS' 'a41 �1 ,( .�f � mlii.^_1i; m1.\lk lt!�
COMPENSATION INSURANCE',,•
'(Thi¢iticoom need not he completed if the permit is for one hundred dollars
(910o)or less.)
I cent fY that in th pe fmosence of the work for which this permit is issue) I
)hell not employ any person in any manner so as to become object In the Workers
Compensation laws of Calibmia.Date '
NOTICE TO APPLICANT:If,afmr'making this Cectihcue nl E¢mp,iom:yW,hould
become subject the Workers Compensation'pr.vi,i°ns of rhe Wbar Cola you must
Q O forthwith comply with such provisions or this permit shall he deemed revoked.
E'V] ' I "CONSTRUCTION LENDING AGENCY
F'' . 1 hereby air,.that dome is a coronation)ending agency for the perforance
of the work for which,his permit is issued(Sec.3097.Co.C.) m
HiQ ' Leder',Nnnic•_.. . . . ...._. _._...
�;j.Z Lender's Address
V' I rectify that 1 have read this application and su,c that the above information is
corrict ague to comply with all city mid county ordinances and state laws relating
to Wilding conamction:and hereby authorize representatives oflhiv city to enter upon
r [xi the W e e I ed p pert f Nuct ri p red s
(W) grc susave,rode 'fins rhaml it the Cly fCupertinouair,,
against
Vj Ctliabilities,judgments,c sty o f xpe'se torch y t any y pain:t.xiJ
_V Z City in come cof th g nt ngo rah perm, - '
AIPLICAS U6RST\NDSAA'I I LCOMPIY'YITI AL A I `
Sok(cEt. T,rtal A Ions.- '�i Issued by: Date
Signature. ApplkmndCmmr in Date Re-roofs
-H\ZA OUS MATE ALS DISCLOSURE
W 11 tic app,., I fI' b Idirg p , tore or handl bzallops mamrrl _.Type Of ROOF— _.. ._.._.__. .. ._..- „..,,. _. .�._....._.,_.....
as defrost by the Cupcnn Muniip l Code. Impacr 9.12, l the Health add Safety - '
Cor s f n2553at I " ;'II t. 1 - �,a:'t I,I� , (.3;:'i,yii. yl_':f
°Y _ All roofs shall.be.mspected prior to-any roofing material-being installed,
i
Wil I Ib ppi drunt or future n'lai g decaparit use equipment or des;e=.which If a roof is installed without first obtaining an inspection, I agree to remove
em,h N -us airrnparriwart,at def by the Bay Arrays Quality Mang mens
District' all new materials for inspection. Applicant understands and will comply with
°Y all non-point source regulations.
1 have read,he iazardous aterials requirtmen¢under Chapter 695 of he
Califon Health&Safety Code.c ions25505.25533 and 25533.1 urdosamd that
floor h 'I -ng does no,currently av a¢nam.thm i,is my
«sponsibilhy lm notify,he
Oeeua Ne rcgmWona wh ns,bCme,.Orior to issuance of C<ctif9!r,e of
In IV/ Signature of Applicant ._ Date _
:y
Go
- milum:ed agent - \7L Date All roof coverings to be Class,"B"or better .
r ,
. . . .... . . . . . . OFFICE. . . ... ._ .. ... .._.. ..