00120105 CITY OF CUPFRTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
s BU I LDING ADDRFSS;s P \
11. 13 PTAFFORD DR AI_TON AIR CONDITIONIJ9Th11T Ndu HTGO01.c01.05
OWNER'S NAMI?- PPLICA9'ID'Slll1 AG
NELNICK JACK D AND TATYAN A 45300 INDUSTR'IML DR 4 GLOM /a 000
PHONT;; SANISARY NO. CONI ROL NO.
(510) 490-5655
M n% ARCHITBCUENGINEER: - BUILDING i'LNAfI IINPO
OO I11,DG BLBCT PLUMB 611101
w
a
LICENSFI)C)NTRAC'IOR'S DECLAIINHON
z S m I hercnr',nfim,than I am licensed older nookinn,of Charlie,9(.nom ening Job Description
-�°_tW with SectionnxxnorDivision3nnhe[to.me..andprofession,Code,ad,nyii«n,e REPLACE 100 000 FURNACE
,,se -
is,; is in IUII truce lith F� 6 +
¢ License Clas_ Lic.p
,M
Cmnnml.ICA1
u 5 u y f0` /t7 un" s Dac1.ARnTK)
O 4 I unJemm�J my droll Is,nNCHI'recrused ax public me
LL�¢5
p O
Licensed I'mfn,ional
BUILD
Oat I am exempt front
nt the Contractor's
1 nneM1y noinn that a amp, ,an the Comorl,C License t,a fi,r the
t G a whichJollowin,teaam.(coullnil]111 tr L.I. alter,
and Prnle.e io li h,oc'.nay city m'couhe
f O which raprire,a p.'mfil m construct,alcor,impmre.demolish,or repair any strunurt
ce prior q its issuance,also requites the Viaticum(lot such punninn elle a signed ammnrent
chat he i..hau,ad Imr.or,rrt,,,,be pmvr o ofthe C..Imnoln Douse law(Chary«9 Sy. Ft. Floor Area Vi ua[1t�na
(cormnrcine with Section7(Woof Doi)nn dole ltudnec and Prodroi sGNU] f.`4 r
,,,'thuf le is csempt Iheclm.n all Mc brei,for Ill,dill uwmptian.Any violwion
of Section 703 1.5 by any applicant fern fKnnit subjects the applicant o a civil penalty
0 not more than live nomlrtd doua,,(swan. APN Number Occupancy Type
36i_060f'J9.. 00
❑I.m Baer,of the pmpany,or my anpbyein with wore. a edfo ole enmpa,.7(n , dXQ�_
will ne the wnrk,and tnc ode; no is not intended s Li a offered for sill)(appy ]oN. �� .,U' ❑gyp cp
Rusinca n.pll,yWions Code; no, o,tnrumor's License law does not appy w an 301 — ROUGHquF'L�Mtl IVl ns
r of his
Who bolts or ire m,ves thulium,,and who does anon work ruled or
rmmngitada. n employees.
omes a v.pmHdwkthat such imprnt ems areful on. au it 303 — ROUGH IYIECHANICAI_
<JfoplC for sale.B.hnx r',teal have
n• col in sold he did n or
mpwe to,the owner-builder will ham the burden of proving film he did no,M,iIJ or
�f�prave lm paga,.e nt yme.l. 304 — ROUGH ELECTRICML
01,a,ow«r of the roman, incaamsivalycomraeangwhhlicensed aormacl,u, 51715 — FINAL ELECTRICAL
um,muct the ,N,(Sec.]tae,Business and Promssloo.Coale:)Tne Contractor's
an,e Law doe,not apply to art owner of pmpeny who bund.,or m,prnves demon. 507 FINAL PLUMBING
and who caotraats ror each pn,iest,win,a vontraetorrs) licensed punolot m the ;108 — F I RIAL. MECHRN I CAL_
Cnmraaor'8 Liccmc law.
El1 am coconut under Sec. .13 K P C for this ma....
Owner Data
WORKER'S COM1U'CNSA'I'ION DBChARAI'ION /
I hereby allirm undo IN,oly of Perjury one of rhe Ibllowing Jeclmarionv, O/
❑ 1 have and rill rnalntain a Cenifeate of Conan to,elf-insure fur Worker's
Co,npenwtion, as provided fr uby Suction 1]110 of the Labor Code, for the
perfnrmana of the wok fur which this paral in issued,
nJ will maintain O'nrkcr's Cofnrlcnsation Insurance.as required by Section
II
]BG of the labor Code.for file wrfnnmanec of the work for which his permit i.
issued.M/]�'Wa'nde�rS,.C,Q..nien.wtiaan lmurame canierr and Pooh,1 coolie,am:�,� q
Cxrriu / Policy Na.( te
' I IPIGTION OP I:NPI'ION FROM W)RKI-RS
COMPENSATION INSURANCE
('Phis,cninn need not be completed if the Pc,uo is for oma hundred dollar,
SIM)nr lu)
I c.ruty thin in the pedoor.thee of file work for which this pemfit i,ivwed,I
shall not employ any pennn in any manner.o as to Income smbjen w the Workers'
Conymr,atlou Law A Calit'nmia.Dare
Appl ...I
NUI ICF IOAPPLWAN'1':U.ober mak'mg rhia Ceni GemaM l7s,or ,ion,gun stolid
become subject n,the Wo,o,,'s Clausal poll if the[alae Code,you moa
O fonhwimcmuplyx'i@such prevision,ar this permit.hall bedocond«vosad
,
G r
C'ONSTRUCIION o"fill ILG AGI!NCY
x ' Ihitf..wlimr Asan,borei.nc...it(o,. Icndln8 .C.)yror the rlerti,m,ance
of the work far which this permit is issued(Sec.JIM)].CoC.)
, nder'.None
7 Z Z LcLamiar's padre»
V C) I certify th o 1 have rend this applicalion and>Iam that the aMwe informeion is
I.. F., correct.I a8,c'e h,comply xith all city and county(,romances and staln.law.v rclming
Q V m W.1dir, stn I d brief,wild,e P ,leas trh:ailyt er.q,n
r (s; the td,oc-onantioned propeny for inspectionp ror s.6, (We)agree,,, all,indround,toldkeep h ,,Ub,Cly f Cir,eni
a,air,l (B
tP lis n l t . l 18 f t: c r J expenses which may any Y against said
V L
City lin emn.,tonce rl fheb timing fdi,l t ^ �^ ♦ 17 8- �y 1
5O=1.IC Ri )1ST AtinND WILL COMPLY WRH�LL NON-POINT Issucd by. yL T�,v/���Glr Date
12— �Cj VV
IVYod.rlplic,au)S raaor Dale Rc-roofs
IIA' fro"S MAI'IiIIIALS DISCLOSURF.
Will the oil or future Wilding¢apamstore or brsele bvaNrws material Type of Roof
as defined by the Cupcninn Mumiclpal Gales.Chapter 9.12.and rile I learn and Sulety
Click.S«,inn 25511p0:'
0Ye^ All roofs shall be inspected prior to any roofing material being installed.
VY ill the applicant or future building oa.vpunf use equipment or device,which If a roof is installed without first obtaining an inspection, I agree to remove
t hnaokoi,air c,uu ninants as d,fiucd by he Bay Arca Air Vu'alky Mam"ouncmt
nii'ldat^ all new materials for inspection. Applicant understands and will comply with
0 W ciao ' all non-point source regulations.
I have mad the haeal material,requirements under Chapter(395 of the
if the
buil ing dos Surety Coda avetit t n ant.that
it is red responsibility
l undedand the �) Y
ifrheaint olnSdoe,notcurrcmlylovea¢Bout,,clot iris ,, ra.rym.ihila armollfy the
m'uPwt nl'rhu myuimrncn rich mm�t be run prim to r6wr'vncc of n Canilicntc of
0...pan,,.
a Sign.1V of Applicant Date
o nes r aumnnawagemt Dnm All roof coverings to be Class `B" or better
OFFICE