02070069 (2) CITYBUILDING NG uPERTNNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19955 PEAR TREE LA A B S HEATING Se AIR GOND 02070069
OWNER'S NAME: APPLICATION SUB DATE
MISHA DRAGOVEVIC 334 SHAMROCK DR 07/12/2002
PHONE: SANITARY NO. CONTROL NO.
(408) 238-7178
.0 O O ARCHITEC (ENGINEER: BUILDING PERMIT NFO
q,p BLDG ELECT PLUMB MECH
aiW t—I u - 't CJ
Z'
Z S dl Z LICENSED CONTRACTOR'S DECLARATION Job Description
O Z-0 1 hereby affirm0).f thin 1 am licensed under Pmvinons of Chapter 9(commencing
pN-S with Section 7001ry of DivizionJ ofth<Businasand Profersiom Calc.and my littntt FURNACE & A/C EXCHANGE/DUCTS
m in full force and Sf t. (`
°•O cd U License Class "l �It. Lic.p 1
Dina 'l -i2-n7 Cmdrscmrg _
yuS 3 u .ri ARCHITECT'S DECLARATION
01 1 undcraand my plans.shall be used as public records
to
ad
da i o
O Licensed Professional
m 2 OWNER-BUILDER DECLARATION
I hereby aRnn that I.,it eaempt from the Contractor's License Law for the
F•Z a following mason.(Section 7031.5.Business and Professions Code:Any city or county 2 5 0 0
E x O which requires a permit m construct,alar,improve demolish.or repair any stmcturc.
W 3 ae_prior to its issuance,also requires the applicant for such pserna to file a signed sm¢ rn
mt
that ho i(licensed puremap t6 aqe prudst°ns of the Contractor's License Law(Chapter 9t or-A ea- Valuation
(commands,withec
Stion,7000)of Division 3 elfthe Bys1nyan
sd Pmfcinns code) {`i)_+;'j'i31\.b3': .0 a..iObrdZ:43.�.r'Rv'i'
or that he'k coo t therefrom end Mc basis for the alleged excurption.Any violation
of Station 703 L5 by any unit lams for a permit subjects the until cam to a civil penalty
rofnot mom than five hundred doll.(x500). 301APNH�UGH PLUMBIN " Occupancy Type
°1,as owner of the property,lar my employees with wage,as their sole compensation,
-
will do the'work:'and the structure is not intended'or offered'for sale(See.70x4,"' - 303 QGUGH
'Business and Professions Code:The Contractor's License law does not apply to an 304 - ROUGH EL)L9Gt1JR21 )sXctions'"
owner of property Who build.,or improves thereon.and who does such work himself
or through his own employees.prided that such improvemLnts are not Intended or ....505_ =.__.FINAL .ELECTRICAL....- .. -_ -.._. .... __.
--eRrned for sale'.If.howiveElhe building - is add.vibm one of ._ ..._._-_.. ...._._._ ...... -. ...
Id t due that he did not Wimmr 507 - FINAL PLUMBING ''' '• '''
amp c ion. Proving
improve fapum°m°faale.l, 508 — FINAL MECHANICAL
�°1:as owner pr the property,am exclusively contracting with licensed Common is
icewm she project(Sec.71.a Business and Professions Code:)The improve,
tmcemi, „. O. V.
License Law tr c nm apply m an owner m a conty who builds s improves thereon,
and.who.c,LicenseLaw.ch Pmjens.wimaconvocmrts)littnsed pursuant m.the. ._. _ ___. . ...-
01 am exempt
pt under
law.
❑lam exempt under Scc.' .B'&PCfor this motion
Iaras�wr-'n1' 1 ".Clt;
_ Owner-" Dare
WORKER'S COMPENSATION DECLARATION q
I hereby affirm under,Penalty of Perjury one of the following declarations:" AUG O 5 20OC
° 1 have and wilt maintain a Cedifcate of Consent to self-insure for Worker's
Compensmion, as-pruvidcd for by Sermon 37W of the Labor Code, far the
perforriunce of the work for which this Permit is issued. BUILDING V I I 1'9I p I/+_
®1 have and will maintain Worker's Compensation Insurance,as required by Section 1� Ll.i 1 V Vl
3700 of the Labor Coale,for the performance of the work for which this pcmtit is
nx
N MyW iters Compensation lnsumnce camcr stud Policy number am
c: lZAt=iifF. VPnit<rNa O H¢1 p•{3 5 itF: \r a
.(/ s, 10ERTIFICATION OP E%EMPTION FWORKERS' .. {h t� R �7av�t� ' ,/,
' COMPENSATION INSURANCE'° ' " '
(This seciidi need in,W completed If he permit is for one hundred dollar,
IS I W)or lees.)
_ -'1-certify that in the m furmmce of the work for which this permit is issued,I
"shod,hot employ any person in any manner so as to become sabjeci to the WorkcrA -`
Compensation laws of Cald m tt.Date
Applicant
NOTICE TO APPLICANT:IL art,,making this Certificate of Exemption.ypu should -
become subject to the Workers Compensation provisions of the labor Code,you must
-
Q 2forthwith comply with such provisions or this permit shall W deemed moused,
_'..... . .-"-''- _.. - - . . .-_. . ._ "
H i 'ae:` CONSTRUCTION LENDING AGENCY" ' r,
da ' 1 hereby affirm that them is a construction lending agency for ther
perfomance
r of the work for which this Permit is issued(See.)097.CO.C.)
Lender,Name... ..._..u_. . -.. __....
7.Z Lxndcr's'Address' ..-
V � r), l eerify that l have read,lik ipithicnimi and slate that tlax idt information is
Ls�.E comma.I agree to comply,with all dry and county ordinances and.state laws relating - )
Q V to Wilding construction,and hereby amhmim representatives of this city to enter upon
>a fry me above mentioned property for inspection purposes_,
Fy (We):iumv ,,love,indemnify and kkp harmlcs the Ciy of C.pam against
' (n liabilities,judgments,costs and caPensas which may in any way accme against said
U City in corsu9uencc of the granting of this permit. .mit. ' ' (",
APPLIC aN"1'�1N ERSTAND$,\Np\,'ILL CObIPLY\s'ITH nLL NON OINT' Issued b Date
5UlIRi .ItJ 11�'w nNS. .e :r 6.,. .--,�47.Lt y /
Sig ^_ fmff AApplicanUCont tof Dam Ke-roofs
HAZARDOUS MA'TFRIALS DISCLOSURE
Wll the pplic for ficam,lw'lloccupant tore or handle hamNommte' l - Type of ROOF _._ ._. -.. -.. . _ .. .........
as derives!by the Cursnims Municipal Code Chapter 9.12.and the HcalN and Safety
Cod Sto255R11 i..`f' 1'� '•S � s s.• s:
••°ve, 'tuCln ,. b.-4 "1, : _All.roofs-shall be-inspected prior to any roofing material being installed -,
- .will the applicant orfuture bohdingoccupemuse equipment ordevices which. If a roof is installed without first obtaining an'inspection,'I agree to remove
emit hmardous air contaminants as derived by the Bay Ar_4ir Quality Management
Distrito? all new materials for inspection. Applicant understands and will comply with
°Ya';, 13�a"° all non-point source regulations.
1 th i,c read the ha,iadouo-materials requircmems under Chapter 6,95 o1 Me
California Health&Safety Cale.Sections 25505.25533 unit 25534.1 undercmnd that
if the building does not carnally have a scmnt,that itis my r8ponsibilitym nodfy the
Occupant at the requirements which main W met prior to i.smanc a Cerificam of
° ".`3_ _Signature of Applicant Date
Owner rmrthuncedload ,Date All roof coverings to be Class"B" or better
OFFICE