01100136nu;
r
em
CITYILEHNG
DIVISIONPERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
10266 VIRGINIA SWAN PL
CONDITIONED AIR
01100136
OWNER'S NAME:
APPLIC TION SyB DATE
ANJALI ARORA
164 B GILMAN AVE
10%25/2001
PHONE:
(408)374-6311
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'"-1 I l L —J L.1
LICENSED CONTRACTOR'S DECLARATION
Job Description
pt
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section ]u�B)of Division 3ofthe Business and Profession Code, and my license
100,000 BTU FURNACE C'HANGEOUT
is in full forte and eHccl.
License Class Lic, p
Date Contractor
ARCHITECT'S DECLARATION
1 undersand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affrn ,lm 1 o entpt from the Coalramar'x Lleanse Law for the
following reason (Section 7031.5.eBminms and Profession, CWe: Any it,, -county
$521
which requires a permit to couturier, aper, improve, demolish, or repair any slrucmre
..pdo t n aneaalxo q dap licanl for such Permit to file a.'gretl ueurrrent
El IaY' '1 '7\LT:.,1
Valuation
puiminno00)ofdst sision She he BusinesL rsse La ons Code)
(tom n
(commencing with the Buxinesaand
imsnt Code)
The
g tonna) baron3.f
ne is li and ,or maxis for the Any violation
of cateran bri,An vi
l��,k \e - 1�1�:
i
- of Section ]031.5 by any applicant for a permit subjects ,he apAlicanno a civil Penalty
Sec 335 by any applicant subjects the to
:.f not mmehanfrvehandredcall. (s5ad).
301APNllt @ PLUMBIN
""'•' Occupancy Type
❑l. as owner of the prupeny, or my employees with wages as Their sole compensation,
303 ROUGH MECHANI
AL
,WillBus ne fine work, and me xvucmm is not intended d er offered Law doe rale apply to a,
do t and Professions Code: The is not i ten License Law dor not ..c. m e.
3 04 - ROUGH EI$]D(AITi 3JIBR*tions ..,
'
.,air, of progeny Who builds ar improves thereon, end who does such work himself
505 FINAL ELECTRICAL
or enough his own employees. provided that such improvemems are not intended or
'-
offeree for salt. If, however, the building or iinpovcmem is sold within one year of
_- _ _
507 - FINAL PLUMBING
completion, the owner -builder will have the hurden of proving that he did not build or
mpovermpurp.xeoraele.). -
508 - FINAL MECHANICAL
O 1, as ir_ ner of the property, am exclusively contracting with licensed comm" 0"to-
construct the project (Sec, mM4, Business and Professions CIA) The Cnnuacmr's
License Law docs not apply man owner of property who milds m improves themon,
r
_ and who contracts for. such projects with a contmaogs) licpnud pursuant to rhe.
.... _ '
Contractor's License Law. ..
❑lam exempt under Sfc. s . B A, P C forthis naso.
p�
F .. .
�'E����®
Owner Dare '
''•' ' WORKER'S COMPENSATION DECLARATION
(j O a,00^
MAY
L'A J
L
I hereby affirm under penalty of perjury one of the following declarations:
,_.Cenifiaare'of
❑ 1 hale and AM maintain Consent to self-amme for Worker's
Compensation, as provided far by Set 3]00 of the Labor Cale, far the
p2
BUILDING
performmme of the work far which this german is issued.
❑ 1 have'aad will maintain Worker i Compensation Insumact, as required by Section
37W of he Labor Cada for the pe i mu a of the -work for which this Aetna, is
issued. My Workel,Conpenmtion ftm` mn<e carnia antl Policy number see: „'.
Ca !) t.). ." 'P.IiiY Nb'• .• _
Y(,net l�,4e�.lf �n 1.. st`.�3 �Ltl t:.s 4st. t 1
CCRTII'ICATIONOF,EKF,MF'TION FROM WORKER$'i.,
- '•'tti ,'.., ,!, ;; COMPGNSATION INSURANCE' ... ,;� _
._.-. _ _ ___
(Thia section nod no, becomplered if one permit is for one hurrdmd dollars
t.,.
15100) m less.)
YI' employify ani Performance anis permit is issued, l
- t t,, �. y,� rls•v n r . . , , -
swork tofor become
mall oat employ any in any manner s. as ,o become sunject to the, Workers'
Persnnany manner
f C.1 f
Coihpense,ion Laws of Cvlifonia. Dau
A can,
If. Cher makingthisimovii. Bate of Exemption, youyou
NOTICE Tjec,
`
whCAM:
becbmpsubjecty the Worker's Compensation provisionstheLatin,eemed Code,you must
ll
ronnwan comply with such provisions or this patina mil x deemed revoke,.
'
cons LENDING AGENCY
C(JNSem
•'
is a lendingagency for performencc
`Ihcrcor pterin this themisS
astud. m.
of the warn for which ,M1ix panni, is issued ISec. 309], Civ. C.)e _
�. v-:
I<netr's Name -_.a.. .:. t ..
Lentler's Address'
I ocro y,hat 1 have mad this application and state that the above information is
coroner. agree to comply with all city and county ordinances and site laws relating
.,
Wilding and neuinspectioi of,hiz citymenter apron
Wdaie-mensuued
reposdnnahves
oncd progeny for inspection reposes.
Ne above-mentioned p .
1 We) ig ts save, t and keep harmless the City of Cuporiinolt
dgme
and expenses said
liabilities, judgments, cases and expenses which may in any way accrve against said
City In the granting of IM1Is perish.' '
ANT UNDERSTANDS
APPLICANT UNDERSTANDS'AND WILL COMPLY WITH ALL NONPOINT'
'
]SSUedb Date
SOURCE REGULATIONS...
Y•
Signature of ApplicanUCommcm, - "" Data -
-
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
w'u to ppli=ant N building occupant share or haul barordmrs material
Type of Roof- - - - - -
`• •' - - -t.
aabythCapertonMunicipal ; Code, Chapter 912,and theHealth and Safety
defined-
Codesnion 25A21ele.t ',
a ^•W( r>•'v - s I 1
°'se'6'' 7p �.1"_N 1.-SLYS.i•.:1.:r•.
,atop 11>�
❑Y s ;O No�-_All
roofs -shall be -inspected prior to any.roofing material being installed.
"l'witimeapPrean..r'mturpbuildingOccupantuseequipmentordeviaxwhem
'
If a roof is itisialled'without first obtaining an inspection;' I'agree'to remove
emit hazardous air comate t o defined by m B y A. A Quality M nagement
Dia, ct
all new materials for inspection, Applicant understands and will comply with
❑r x o d „; - :
all non -point source regulations:.;
I read be et zCode. m regmreme3 6.95 of Be
der255
and25534.(understand that
mil Healthy tions and 4. 1 un
s He Coat.Sections25505t
if
the ofSafetyCur that itis my responsibility
iftheor whichhavuse
_
he requiremnts be prior off rairciytne
acupSm of ,he rtquiremtnh which must be net poor ,o issuance of a Cenifce¢ of
°""P'"`Y'
Signature of Applicant Date
All roof coverings to be Class "B" or better ,
Owner or aath.dapa agent
S - OFFICE