03050057,r
CITY OF CUPERTINO
DIVISION PERMITBUILDING
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BUILDING
ADDRESS:
ATLAS HEATING
PERMIT NO 03050057
859 BETTE AV
OWNER'S NAME:
155 SAN LAZARO AVE
P�dITL n7l3/2003
I TABH S HUKLA
ONE:
(408) 739-0516
SANITARY N0. CONTROL N0.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDGO ELECT UMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby aBllm BW I em liaUsed under provisions of Chapter 9 (commencing
with Senion]g10)o(Dividon Jof NC Businw end Profeasians Code. ander Iimrlo is
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Job Descrlp 1
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in (ullfomeondcB� 26
FURNACE-SPLACEMEN� .'
Lkeno Clm�-r� Uc. •
Dam /2f -T Conuenor
ARCNTfICTS DECLAR TIO
I understood my plana Nall W used u public recti
U/ Jy\\�U Iju{I i
Licensed Professional
OWNER -BUILDER DECLARATION
I hemhy aBhm that I am emmpt from Ne Contrectors License Law for Ibe
following mason. (Section 7(313, Business and Profusions Code: Any city or county
which requires a pemdt m construct, alter, improve. demolish, or repair my mscmm
prior m its issuance. also requires the applieanl far Such permit m nlc saigned srammant
Sq. Ft. Floor Area
that W N licensed puncml m the provisions of the Cmnrmmrs Liam Low(Charmr9
$1"Jition
(commencing with Section 700M of Division 3 of Ne Business and Profusions Code) of
Net he k exempt therefrom and Ne basis for Ne allcgrA cumptlon. Any violation of
er0 0
Occupancy Type
Nm Obe myhunapplicant for a permit Subject, the applicant m a civil Pewty of
not ore
❑ I.MOwnerof NepmpwymmycmployeuwiNweguutheumlemmpe=lion.
-
Bions
will Me Ne work and the summum u not intended moRered fm Ask (Sec. 706/, Business
and Pmfwiona Code: The Contractors Limme Law dam rot appy m an owner of
303 - ROUGH 1.1
property who builds m improm Nermn, and who doe mush work himself or through his
mnemployeu,pm &dal=hlmpmwmenuuenolmrendermartendfmWe.IL
304 - ROUGH ELECTRICAL
howeni, the building or Improvement u old within arc yearof mmphtim. Ne owner.
Wilder will naw Ne burAen of poving that he did net Wild or improve for purPoo of
505 - FINAL ELECTRI CAL
am
507 - FINAL PLUMBING
I, u Owner of the property, am exclusively connoting with licensed convaemn to
508 - FINAL MECHANI CAL
construct the project (See. 7044. Business and Professions Cade:) The Conrncuu's Li.
mine law does nal WIY te an mmer of property who Wild, or Improm Ihemm. Sod.
who mnrrem for such pmjem with a conuanort0 licensed pursuant m Ne Commanoes
1-iccnw Lew.
❑ 1 am exempt under Sec. . B & P C for this lesten
ner Dam
WORKER'S COMPENSATION DECLARATION
1 bereby affirm under peony of perjury one of Bc following declars0ons:
I have and will maintain aCenilicam Of Consent 10 Self-InSum for Workers COmpen-
on, u provided (m by Station 3700 of the labor Code, for Ne performance of Ne
rk for which Ni, Permit Is issued.
IMY
,
1 have and will maintain Worker's Compensation Insurance, u required by Section
0 of the Labor Code, for Lou performance of do work for which Nn permit is issued.
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Worker, Campensaden lmmmnce carrier and Poliry number a rt:p�rtier. S-?for-%I_,� Policy No.:wLW-435(97p.S
CERTI CATE�PTION FROM WORKERS
COMPENSATION INSURANCE
(Thksection Seed nor he completed HBO permit 1, forone hundred d011ars(5100)
m ms")
I certify that in the performance of the work for which this permit is issued. 1 shall not
employ any person In any manner an u m become object to Oc Workeri Compeaation
Laws of CalIfm dL Dam
Applicant
NOTICE TO APPLICANT: IL after making Nk Ccnincam of Exemption, you Should
become subject m the Worker's Compensation provisions of the labor Code. You muss
fomwlrh comply with Such provisions or this permll Nell be deemed mmked.
CONSTRUCTION LENDING AGENCY
(or the performance of
I herebyalfvm that Nem isaoo(Sec.
307. Cm .)
Ne work for which this patron is iasmd (Sec. 7097, Civ. C.I
- 1
Nude
.
landcrs Address
I ecmify Met 1 have read this applicatlon and stam Net the above kmmeadun It
1 agree to comply with all city and county oNlunces and Aute laws misting he
building construction. and hemby mthodne mpoeseostim of this city to enter upon Me
move -mentioned property for inspection purposes.
(We) agree m ave, indemnify tib keep harmless me City of Cupertino against
liabilities. Judgments. eau andexpemu which may in my way aernle aWnSI aid sty
In conoquento of the granting of this permit.
APPLICANT UNDERSTAND D WILL COMPLY WITH ALL N N -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Sigmature of ApplicandConlaclor Do
HAZARDO SMAIERIAISDISCLOSURE
Will the applicant or furore building occupant stare Or handle haardous material
Am defined by rite Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
m e. Seed. ns32(a)7
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building =upon, use equipment or devices which
it havaNnus air contamkanu as defined by Be, Bay Arta Air Quality Management
all new materials for inspection.
imict7 ,,,''/
❑Yu yyam
I have mol the naamdousmamdals requimmants under Chapter 6.95 crow Califor.
nia Health&Safety Code, Sections 25505,25577 and 25534.1 understood that lfNe building
does mol m mull mnan4 Nal h a my mmomihillty m andl'y do omupant of IW
reyvirtmcnta ch mus croup' mivuanccOfsCcnificamofOcu Y
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or auNmi ad • em DTs?
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CUPERTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
03 e> Sro °s^ 7
APN #j �j
Date:
BUILDING
/. BREMFURN
Building Address:
MECHANICAL
.5 9
A/C Unit > 10,000 cfm
Owner's Name , �
�,,�"
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Phone #:
255 - 6 z3
Contractor: Phone:
— 03/6
License #: 6s Z to 6739
Contact: v Phone:
C,�fil�riyui �^'---
Cupertino Business License #:
Building Permit'Info:
BSEISMICRE
Bldg ❑ Elect ❑ Plumb ❑
Mech
Job Description:
Elec Permit Issuance
Residential Commercial ❑
MPERMITFEE
For Rg,� idential InL llations:
MECHANICAL
Attic LJ 1St floor 2"d floor ❑
Plumbing Permit Issue
Adhere to min set back requirement ❑
BPERMFEE
For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural calcs) r-1
Plan Check Fee
Structural Calculations required for new installation ❑
BUSLIC
New installation Planning Approval Required
BUILDING
Cost of Project: Type of Construction:
Occupancy group:
/(0 0 2 • O -D
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Re lacement
Qty. if
Anolicable
Fee ID
Fee Descrintion
Fee Groun
BENERGY
Energy
BUILDING
/. BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfm
MECHANICAL
BREMRECEPT
Rec d, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMITFEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING
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