02060095 OF
TINO
ct BUILDING DIIVIiSSI
iONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
1166 STAFFORD DR SCHAUMANN AIR CONDITIONING,
ONDITIONI G, 02060095
OWNER'S NAME: APPLICATION SUB DATE
HAVENS RICHARD A ET AL HEATING k PLUMBING INC 06/17/2002
PHONE: (408) 428-0640 SANITARY NO. CONTROL NO.
00 ARCHITECTTNGINEER: BUILDING PERMIT INFO
w G- BLDG ELECT PLUMB MECH
u
1-'-I 1-1 L_1
LICENSED CONTRACTOR'S DECLARATION
5� I hereby aferm that l am licensed under Job Description
pz_o tPmt.of..Coxi9mommendng REPLACE FURNACE/ADD AC UNIT
t..,_Ew with Section 7000)of Divisionlof me Business and Pmlcssions Cale, myliena
'Y27 is in full force' .7
oe m a Lice, las 0, Llc.a
ed
3 LL N Dal S 'in[IOr �a
ARCHITECPS as pub' NAL E®
O 5 I undcnranJ my plans mall be used m pub'
Ieri ds lith
a.8Y
�a o Lie<mxd Pmfeaainrr°1 JUN 2 6 2002
v LL OWNER-BUILDER DECLARATION
1 hereby ofNm that I am exempt from the Contracrnr's License Law for the
t 3< following reason.(Section 7031.5.Business and Prom,vions Code:Any city or county $6000
Y F o which requires a permit to consumer,eller,improve,demolish,or repair any stricture
prior to its issuance,also requires the applicant for such permit to Gk a signed statement
that nq is I'mosed Pursuant to t�hp pry.....a,of me Ommucmrs License Law(Chapter 9
(eommen ngwimseclinn7D�)ofDi„.inn3ofine��VVme,pd�ipr9ssian.Cne) +36' ;� %%E3�3� f z[''I;\`'S(' Valuation
."hot he is ciempl themfinin and the basis for the all(ged immpl m.Any violation L{” - ] .. _ l.w s x i s'
of Section 7031.5 by any applicant for o permit subjects the applicant to a civil penalty ..��{E��ss,�.as�sJJ.�pp��
of not more man rive hundred dollars(SSW). 3 01 APNAbigt5T1 PLUMB IN I o%:;, Occupancy Type
CI 1,as owner of the property,or my employees with wages as their sole compensation. 3 01 - ROUGH '
will do the work'and the structure is not intended ffered for sale(See:'7044 -"
'Business and Professions Cade The Contractor's License Law does not apply to an 304 - ROUGH ELEC fTReEQ&Iections' ', " r
owner of property Who Wilds or improves thereon,and who does such work himself 5 01 - FINAL ELECTRICAL,_ ENERGY
or ired fa his own employes.provided that such vementemems are not intended or
oRered for sale IL howbvcr,me building or improvement is said within Dire year of --- '"_.. _...__ ...... ...... ._...__._... ........__-._........
502 - FINPL PLUMBING ENERGY':
improcdopletion,the vefor purpose of sale.).
will have the Horden of proving that he did not build or -
503 FINAL MECHANICAL' ENERGY
o 1.a_wnero _Pm y ..._--Y-----i_,_. .. ..maim .._ ... ...-505 -------FINAL; ELECTRICAL
'mownwn¢of IL< xduslvel commotio w11M1 lice ad conlrumors l0
the project(Sec.low,Business and Profusion.Code:)The Conium,x 507 - F I NAL PLUMBING
License Law does not apply to an owner of propeny who builds or improves thereon,
..i -.and who contracts for.such,projects.with.a.contractors).rcensid.parmant.m.mc --__..__.-- .5'0'8-' 'FINAL -MECHANICAL..._..__...-.._............ ._._._...-.._..._..._.._... . ..-.
Camracmes License Law. _
❑loth exempt unVlcr See 119 %k rcuson : 'J;:i.l'Ita!ui
Owner ''Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm undrrpe'aally cf pµrjLY one rime following declamlions:'
❑ 1 have and will maintain is Certificoic of Consent to self-insum for Worker's
J Compensmam.iias provided for by Section 37M of the Labor Coale, for the
pirfmmaner of the work for which this perms is issued,
❑I have and will maintain Worker's Compensation Insurance.os required by Section
37W of da,LadW,Code,Ro'mi perfmmance of the work for which his permit is
ins' JM Yrke .0 .all Instar - croi Pot y h n
��/ppy�r Policy
'- 9+4(f
s i01
Ce , ,rCERTIFICATIONO XEMPTION'MOM W R ER61: ��? ± ••? Lf.. h' '�7 fh1 ,MY all I1y V
COMPENSATION IYSURANCEs^ .......... .......____._-_...,..—._._._-...._.__....._...._..-..... _...
' Trans uilibn neJ not be compleieJ if the permit is for urt<hundred dalton "' "" -
(EIOO)orarlcsa)
-t ceriify,ihat in iAe peiFmr;ancc of the wosk for which this permn rs lsxard.1 . 1
.ih,ll not employ any,person m any manner.so as m become subject to the Workers'
Compensation Laws or Carromia.Dale
..AnPtieam ..
NOTICE TO APPLICANT:If,after making his Cenilicam M Exemption,you should
become subject to the Warkees Compensaiioo Provisions of the Labor Cale,you must
Q O fo llb comply with such provi.vians or his permit shall Im deemed rrvoke&
"CONSTRUCTION LENDING AGENCY
I thereby affirint that(firm isaronstweilon ciedinagency for the perfama nce
th
W..� fwork far which tM pc t J(S 3097C C) n ..
y'tz Le d N
V:Q is
t ri fy lh'tln halleppl t nt.fl mon Ira information,,
n
W'U to
orrcn.I agree tr comply M':tbrd ,all oily a d, repreordinances and sate lows relining
QV 'hembongcenstmnion.acay foin,peconurePresntalives of thiscitytoenmrupon
}.LP7
'he b c t eledp c.nYf and P rm ..
E' G
(We)agreets do peandk ph 1 ss theCity f craca aiagains g� /
h Cit I 1 1 Jb 1 J sponse hicheras may m anY Y cc gams)said (•/\/
V'z Clyconsequence
Dfrim grantingnfthpe il.
r. SOURCERLGULA'0 SNDSAYDWILLCOMPLYWITHALL\Op�FO1N1' Issued by: �+ Date
Slgnure of ApM
plicaCnm
naacr - Date Re-roofs
m
y p �MATERIALS DISCLOSURE r
CI Y" ipoCnds,Chapt t renin w na,�dna.nd material Type of Roof. .._ ... .__.. _ .... .---._._. _. .__....
Code.definedbyCu nnoM CW Chapter 1.12.and mcH Health and Sulry I
Code Section 255b(b) i tj 4YI'§r j ' k:[;@'ni^+1j , a' �.
_ ' r " ` All roofs shall be.ms ected npr.tgan roofin
Will the appl c 1 fume
.:, p- _ p y, g•material.beinginstalled.
Will the applicant orfuturebuildingoccupantuseequipmentordevice;which If a roof is installed without first obtaining an inspection, I agree to remove
con,hd ani« lamruams sdefined by the Bay Are,Air Quality Management
'ban", ,., all new materials for inspection. Applicant understands and will comply with
Y- all-non- Din[Source CB ulations. v
I'hxvc read the hoeardommateriAs requircmenls under Chapter 5.95 OI me
California Health&Safety Code:Sections 25505.25533 and 25534.1 understand that
ifthchilding does nm currently have a moanphm it is MY responsibility to notify the """'
oecdpi d f the requirements whigl��r�rnttun be mel prior to issuance Of a Certificate
%W( //
/o j'���//ti Signature of Applicant Date
... GL'` �� ... . . _. _. .. ._.....
nut Miue'ag�ent .. Datp.. All roof coverings to be Class "B" or better
at t •....' .:__ :.:. :. .. .. .. ... .. ... . ..OFFICE..