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01080102 (2) CITY OF CUFERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDING ADDRESS: PERMIT NO. 1152 SCOTLAND DR ATLAS HEATING 01CC0AA80102 QVE9�s1 ' THEODORE L AND SHIRLEY 155 SAN LAZARO AVE A08�20M01 PHONE: (408) 739-0516 SANITARY NO. CONTROL NO. O ZO ARCHITECrENGINEER: BUILDING PERMIT INFO Y w= BLDG ELECT PLUMB MECH aiw �y� Z LICENSEDCONrRACTOR'S DECLARATION Job DescriptlOn OZ- lnercbynrem,mmlamfianmdanderpravis:ons of CM1aper9(commrcncing ADD A/C & REPLACE FURNACE. rr yl-j wirM1 Section Division 3 of the Business and Professions CWe.and my license a " a' rarer and err t. as 6 License CJ�ss CJ - Lid.M Z O U D. _pj � Contractor L a h ARCHITECT'S DECLARATION C-O? 1 understand my plans shall be used as public mereds ad z p i Licensed Professional Q. OWNERBUILDER DECLARATION ca o m i hereby affirm that I am exempt from the Cuormmrs License Law for IM1e F_ a following mason.(Section 703L5,Business and Professions CWe:Any city or county $4000 F .p wh ch requires a penno 10 Construct.alter. P e demolish. pi y stmchod a -s priors s 1. req thef suchpe u fl ' tgmmm d some - - of .. that he se- d purradint totM1 pravNions oftn Contractors License La (Chapter9 . 36U216tl 1! Pf 60-'a . - Valuation montmcncmg with Section 7000)of Division 3 of the invoices d Professions Code) s S or that he is e.acron therefrom and the basis for the alleged exemption.Any violation -nf Section 7031.5 by any applicant for a pcened subjects theapplicam au a civil penally of sot more than five hundred dollars(S500). 303ARN NOUIGH MECHANI AL" ' - � Occupancy Type ❑l.as owner of the propeny or my employees with wages as'her sale compensarnn. 304 - ROUGH ELECT AL _ will do he wan;,and the monere is rat intended or aurrcd for sale fire:7044. 505 - FINAL EI glTi�d 4tr Sections r Business sad Profee,ani CWe:The Contractoro s License law does nor apply an owner property Who builds or improves thereon,and who does such work himself 508 - FINAL MECHANICAL or through sal own employees. bum:dr that such improvemem.v arc nm intended - bRcrd for vie.If.however.the builJin - '� valid !thin one f g or nnpmvrnmm is m Year o ... - ...- 1 nmmleeinn,p r ar,of tai e.).will have the borJen of proving rhm he did nor buil)or ,pmve for pur{nsc of sale.L ' ❑1. ow or rhe p ec tv sly t e g ih I' d r van.to construct a p j t(S ]M4 Businads Professions CW IThContractor's I _ Cresta n r )plyr f p pony h Wild, improve,Merest, nJ h cc o tracts fim.such p jec¢with it commercials)licensed purrestain ro Ne _ __ ... .... - .-.. .. _-_.._. _.... Cm lo"Liefro,1'.. . .. ... ._. .. ❑Iv xempt under Sec ,11&PC for this mason _ .. Owner Dam _ WORKER'S COMPENSATION DECLARATION V 1 hereby affirm under Penalty of perjury one of IM1e following dwlantions: v/VJ O 1 have d ''ll maintain Certificate f C nsent m self nsurc i for Wm / Compensation. s.provided f by Sat 37W of three labor Code. for the .^ perfo f the work f h this perm r Bed ❑1 have and will hidelam Worker's Cnmpenmtron Insurance,as mymmd by Section 37W of the Labor C&I I the per m e f rhe work,for which this Permit Y .surd My -rs Com, :1 1 umnc dPolicy be are: -- Camm �PoliryN ./�7 .. .. .. -._. ._ ..—. _ _ I ... .... .. r CER AT OF E`(EMPf10N FROM WORKERS' COMPENSATION INSURANCE. . ._ . .. ._._... 1"(This¢cfwd need not W completed if the permit is far ane hundred dollars - - - ($1004 or less.) ... .. ... .. . ... .... ... .. _ .. . . - .. I reify 0a in the porn any .(.heo ark r r women ut pt 1 issued.I - C...nnl mnploy Noy of California. in manner so as m Mcome sublen m the WurkerK , Compcnsvion laws of Celifia.Da¢ Applicant. ._. . _ __. .. .. ._. .... .. - ._.._. .... . NOTICE TO APPLICANT:IL after nuking this Cenilicam of Exemption,you should - Income subject the Worker's Comsmion provisions of the Labor Code.you must 0 ttpcn forthwith comply with such prookinn,.,,his permit shall W deemre ed voked. . . .... _ .. - .. _.. _ _.. . . __. _ .. ...._ ._.._ .. ..._._.. _.. n I'R `Ln " CONSUCnEN ON LENDING AGCY r ' "'1 lichebj affirm that there is a construction handing agency for the performance 145'� of rhe work fur which rhi.permit is IssneJ(Sk.3r9],Civ.C.) 0. -Lenc Name -. ..__., ... - ....._ .. ... . . _ ..._ ._... __ .. . Lender's Andress V I certify that 1 have read this application auction.that be above information is career.1 agree m comply,withal city and county ordinances and state laws relating Q C:7 to hildingconstruction,and hereby authorze mere. dives efro city to enter upon r,W the h mei •J prevert,ffy and p P .Fi rt' (Nj)agreerasa indemnify andA p harmdthe Cly of Caperton agmnM /O/,vim/ ✓ M ctyin liabilities,judgment,rc.c s and penseewhich may any y ecme against said !N '- : (.) Z City in conayuence of the grmning of this pcimit._ ' . 'APPLICANTONDERSTANDSAS PILL COMPLY W'IT ALL 'ONPOINT Issued Date /I —Al; - b� S-Ot;gCiv.'REGULATIONS.' Y r Sign rAp,l,'nmJC Dam Re-roofs HALrA US MATERIALS DISCLOSURE W 111 m 'Plica t fore building median,store or handle n rallous materiae .Type of Roof 'ox der dby'h capon 'pal•Codc Chapter 9.12.and dHealm and Safety YP Code Section 25533(a)P , f,.. ',.. ­­ C) . C)Y. ❑N ft .. All.roofs shall be inspected priorto any roofing.material being installed._ .. Wdl th dicholo,lar cWild,rcrapad, or cqa Pment device,which If a roof is installed without first obtaining an inspection, 1 agree to remove emit M d w r cant is as defined by theBay Area A Quality Manam grent District? all new materials for inspection. Applicant understands and will comply with ales ON, 1 " all no source regulations. 1 - I have read the hurmdms materials re,rimmeel,t a tr Chapter 6.95 of the California Health&Safety Code.Sections 25505.:5533 and 35534.1 understandthat iftheb IJ gdoe.notcaurenJvhave a tenant that n n my resp o ibtlny nnmiry rho - occupant f therequirements wh ust mbe met'no,to sus a of u n hate of urn p' / Date Signature of Applicant ._ .. net oraathorizedagen, Date All roof coverings to be Class "B" or better fte ar ... .,. ... .. _ OFFICE _ ..