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
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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 _ ..