00070157 ICITY obi CUPERTINO CONTRACTOR INFORMATION:
nuu,otrvc on'tstory. PERMIT
BDILDING.\DURESS. ' '
PERNU'r NO '
*� ARCHITECT/ENGINFER WNIiR'$NAli, APPLICATION SUB DATE r -
20694' ACADI.A,:COURT ATLAS HEATING :000701.57•
` ONE r ° SANITARY NO. CONTROL NO
Ij CHAN 155 'SAN LAZARO AVE 07/25%2000'
BUILDING PERMIT INFO
+BLDG ELECT. PLUMB MCCH
<�E (408)739-0516
ya`N
LICENSIi a CONTRACTOR'S DECLARATION TION '. Job Description
yZ
S 1-C I hereby mTirm that 1 am licensed under Pmr,aons nl Chapter 90.'mninenung
Fyt:m wvM1 Semton]WOlnf Uinuon Jnf the Husinc++unJ Prnfesaona Cede,and mylmensc
a y g n abfu111mce and of ml. '
nice, Lmensc Class Lic,p �� i.
O a U Dale CI)ECLAr_��
3 0 RCHITECCSUnavino TI
u O< 1 understand my plans+hall M1 e used s public reared, A/C
K-6F •'
a x Licensed Professional -h -
Oat I am acript R DECLARATION
tr-z m 1 hereby a(SM(on 1 1. exempt from the Contractor's.,Cc Any c Low for the - -
t-zr mhichingteaumermit n'lcoLS;Bo+me, ana lve,demolish,or Any cityo inuoury '
S t p xhich rcyuirc+a perms to conswct,alter,improve,dcmnlnh,ar reran any amaurc r - _
n3- Priorroo,nance,also regmreslhe applicant formch pcmut to file uegned,moemem
mathenl+cenmdFureaanitnthapro.ramnSafineCammetaral.ican+el..ascheitcro Sq. Ft. Floor Area Valuation
gcommenang with Section]018)of Dn,son J of the Business and Pmfosion+Cwe) ,
or that he is exempt therefrom and the bait+for the alleged ciemplum.Any nolmmn '
of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty ,
Of not more than rise hundred dollars 55001 APN Number Occupancy Type -
❑L of the pmpcny.or my employees wah wages a,their late compensation, $0
will do the marl,and the structure is not intended or offered for sale(Sec Ikki
Business and Professions Cal, The Contractor\uamov,Law does not apply to an Required Inspections
.act of pmpcny Win Wild%onnitial thereon,and who does such work himself 000170157 ,
or through hit own employee.pnuoded Ihm such impanencen,are not+mended or
ofiered for sale IL hnwevee The budding or imptovemenl is sold within line year of
completion,the owner-builder will have the burden of passing that he did nor build or
improve far purposcofsale.). 303 — ROUGH MECHANICAL
C1 1.al owmer Of[be pml am esclusively contracting with liceawd eunnewhn"+ 304 — ROUGH 'ELECTRICAL '
Lonsuuel the pit9at(Sec ]W4.Business and Professons Chic:)The Comment's
censeLawdoesnotapplytoanmmnetofpropertywhobuild sorunin,e (Incffan. 505 — FINAL ELECTRICAL
and who contracts for such pro)als math a contractors)licensed pursuant to the .
Commit.,v License Law, - 508 — FINAL MECHANICAL
111 am exempt under Sec D&PC hit this rcusnn -
Owner Dam
WORKER'S COMPENSATION DECLARATION ,
1 hercM1y affirm under penahy of penury line of the follnwmg dcclumtiom:
] 1 haw and wdt hinumm a Cemficute of Cumming to self-miun for wader's
Compensatmn, a, provided for by Section Sod of the Labor Code, for the '
performance of the mark for mash Ian Permit is...tied.
and will maintain W'mrkcr'1 Compcns.ainn Imnrnma,as rn.uucd by Swint r
0B of the Lobar Cade,fur the re formonce ofthe work Ior wha.It III,permit '1, '
i\suld.lily Worrk�err'�I Chum maun romance cans,and Policy number arc:
Camcct Lr.(I-"oliey No
W I'i�7 Z/I/�- -
' CERTIFICfI IONOFENF.MPTIONFRONIWORKIiRS' ,+ -
COMPENSATION INSURANCE a
Or
fro,,e l ahead sal be.antpleled it the pennh 11Inr nnc hundred dollan - ..
($RNB ar 1.11.1
I randy that m the pemvm:umc ul the vmbk fm uhlcl+thiv pa n't is i"Ied,I
+hall not employ;if,Pe son is any manna sit a,m bemuse sable,,in the Wni ke,
Compensation Lawsof Cahlornia,Dam" , '
Applicant i
NOIICT:TOAPPLICAN'1'IL:dre„n nation,It'll Caamicum ul liacmption,"la ndaald , ..
hecnme subject er the WodaS Compensation pn+si dun,of the I.xhm Cud.,yun nun, .
Q O
forthwith comply soh such pnwisum+or,on pcnmt dhull be deemed revoked r
V] CONS'I RUCTION LENDINGAOENCI' !
a ' I hereby ufilm last here n a umam.tion lending agency flee the pcdommutc
W of the walk tar which this pernut I,non d(See.3(9],Ck.C.) ,
Ox Q Lender's Name
7 z Lender's Addles+
V C) 1 cen,ry that I lime read this application and state than the above rntermat,nn is,
Lw F correct 1 agree to comply%in all city and county ordmaace%and state laws relating '
'0 (, to building crostmcnna,and herchy authmnz,repremartalvc,ot do,eky toenmrupon the above mentioned property for inspection purposes -
t�,r y (We)agreem save.indemnifyandkeep harmless the City of Cupertino:igama
r Vl habdoica 3udgments,cm¢and circuses whit,nay in any way dame agmnst said
V z City m consequence of the Erdman, f,h,,perms o _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: �A Date
SOURCE REGULATIONS. y' ?-�
Stgnamrcof ApplemaXim amt Date Re-roofs
HAZARDOUS MATERIALS ntoorW1 the applicant sre or handle hwardns material Type of Roof
as defined by the Cupertino Municipal Code.Chapter 9.12,and the iledds and Safety
Code,Section 25532(x)^
❑Yea. 0 N All roofs Shall be inspected prior to any roofing material being installed.
Will the applicant la Same hold,leg«laps.,use cgmpmem at device,which If a roof is installed without first obtaining an inspection, I agree to remove
eon hamrdons air contaminants as defined by the Buy Area Air Quality Management
\nhtell all new materials for inspection. Applicant understands and will comply with
0Ye, °No all non-poitit source regulations. .
1 have read the hinardau+roc enms,regmremems under Chapter 6.95 of the
- California Health&Safety Cale.Sections 25505.25533 and 255341 understand than
if the building does not curten I have nom,,host r+my rcsprm+,hiluy to notify the ,
mcupant of a mgoremenu which st be sect pnor n+n+uone t u Ce r0cate of
o„span, n.�P/ld Tda s
Signature of Applicant.. Date
Dw tnan.eud agent %. Date All roof coverings tube Class"B”or better
U OFFICE .