03090183 CITY OF CUPERTINO .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATIO
BUILDING ADDRESS: ATLAS HEATING PERMIT N003090183
OWNER'S NAME: 155 SAN LAZARO AVE PERMIT ISSUE DATE
LIPMAN PETER H AND CONN 09/23 /2003
NE' (408) 739-0516 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI
jot LICENSED CONTRACT'OR'S DECLARATION lob Description
I I Mreby effort that 1 am licensed under provisions of Chapter 9(commencing P
]jwith Seelum 7")of Division 3 of Ne Busimu and'PJrofessions Code.and my license Is
ej in full(antandl(areeadcff 7 2 �p ADD A/C MNAI_E®
s Z Lkenx Clara Lic.N
Da¢
I understand 1 �C m
e' ^ + h R OnrJ OCT 2 7 2003
C
c�
57"0 Licensed Pnrremand
Oat I am exempt
from
DECLARATION BUILDING
d ME I rawm .(fens that 11. exempt(rum the Contractor's License Law or the
❑O following recon.(Sedan 703 1.5,Business and Pro(cutnu Cale:Any city at county
m which its
n pantie re cnnmmeL alcor.improve,deannit t ri repair any ewnure 74
prior m its i eased pursuant atm requites she applicant far such permiuo files signed atatemcm
�ZG mat mend gwit tion700)of Division
of the Contractor's Licenulaw(ChaptOy Sq.Ft. Floor Area Valuation
(com0.1he .exempt therefrom
and
be main far tftheeged ess exemption.
Any s Cad.)
or 35914045 . 00
thus he is exempt therefrom and Ne buil for the alleged ezemptlon.Any vinlmlon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty a( .APN Number Occupancy Type
not mom than for hundred dollars(S500). - "" --"
❑ Luawner.(the pmperty,or my cmployces wish watesu their sole campenutlon,
will ca the work,and the atrucuintended
re is out u
moffered foale(Sec.7(044,Buircu
and Professions Code:The Contractor's Lt..Law docs our apply W an owner of 303 - ROUGH tLiGns
property who buildsorimprovea thereon,and whodocssuch wart himself or through his L
own employaul provided that such improvements are not intended ororterad forule.If. 304 — ROUGH ELECTRICAL
however.the building or improvement is mid within au year of completion,the owncr-
builder will have use burden of proving that he did not Mild or improve for purpose of 505, - FINAL ELECTRICAL
"le')' 507 - FINAL PLUMBING
❑h as Owner of the property,am"elusively contracting with licensed conbeelaA m 508 - FINAL MECHANICAL
construct the project(Sec.7094,Bustneu and Pro(cidions Code:)The Conuxtori Li.
cense se law donot apply to an owner of property who builds or improv"thereon,and
who contracts for such projects with a contractor(s)licensed purawm to the Convector's
License La .
Fl I ate,exempt under Sec. B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby alRrm under penalty of perjury one of the fallowing declarations:
I have and will maintain a Cenifcate of Consent m sel6iuure for Worker's Compere
tion,u provided for by Section 37M of the I�bor Code,far the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u required by Section
370D of the labor Code.for the performance of the work for which this permit is issued.
My Worker.',Compensation�Insurer,
�eartier and Policynumberare �g
Cartier:2rN�aC i l -- . N^ Pollcy No.: J 7�7ZJ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu it.nerd not M compacted drive permit u far one hundred callus(SIM)
or le".)
I Gentry that in ins perfsrmanc.of the work for which this permit 4 issued.I shall nm -
employanypersoninanymannermutobecomesubjecuoNeWorkctiComcrisatlon .,
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,afar making this Centfcate of Exemption,you should
become subject to the Worker's Compensation provision of the tabor Cade,you most
�O forthwith comply with such prnvisiou Or this permit hall beticemcd revoked.
Z oCONSTRUCTION LENDING AGENCY
I hereby M.that then Ts a contraction lendint agency for the performance of
Y,> Ne work fur which this permit is issued(So.3W7,Civ.C.)
J7Q Larolms Nam.
1 Lender's Addrus
;)Q I certify that 1 have read this application and sure that the above information is
F torten.I agree to comply with all city and county ordinances end sou laws minting to
0U Wilding conswction,and hereby molumm¢prexnlalives of Nis city to care,upon the
>. mova-mentioned property for hurmcdon purposes.
(We)agree to cost,indemnify and kith harmlw tM City of e Cupertino id City
rh incommccoJeoftheerauing expenseswhichmay in any myaccme against said City
A APPLICANT
of the RSTA granting of this permit.
APPLICANT U RSTAND N LL COM Y WITH ALL NON�POINT Issued by:3 Date
SOURCEREG 10 J/
Sigmmrc of of Applicao� • yDT_ Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occu,o nuum or handle huardous material
u cls ned by the Cupertino Municipal Cade.Chapter 9.12.and tM Health and Safety
aWe,Seeean2s532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ye, We"
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It havars u dous air contaminantdcfnmJ by the Bay Area Air Quality Management all new materials for inspection.
utrict7
Yes
I have mad the 6vandus materials requimmenls under Cut 6.95 of tM Califor.
nislicalth&Safety ,Sections 25505. 33 and 25534.1 understM that ifthe building
dose not?xedrac
ve a sense a ' y respo try m ystify the cec pent of Ne
reyuirem Ip r c of c�ry. Signature of Applicant Date
�9�OS All roof coverings to be Class"B"or better
Owner sent D c
CITY OF CUPERTINO ?
SRI- 03 `� vl �
FURNACE/AC
CUPERTINO PERMIT APPLICATION FORM
APN# l v J i Date:
Lsf2
Building Address:/ 0' 2
2J
Owner's Nam . Phone#:
Z55 —�0 9 43
Con tr or: Phone: License#:
� ea. 73 -osib �6sz6C�
Contact/) Phone Cupertino $usin ss License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
�q0—Qyl qC d • 5-
Residential
Residential V, Commercial ❑
For Re idential Installations:
Attic IJ I" floor IJ 2nd floor❑
Adhere to min set back requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required
Cost of Pro'ect: Type of Cons771ynX' Occupancy ge u
Strapped 11On Platform ❑ Bonded Sq.Ft. Floor Area:
New Location A Replacement ❑
Qty, if
licable Fee ID Fee Description Fee Group
BENERGY MA/CUnits
BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER 0,000 cfm MECHANICAL
BREMAIRHAN 10, 000 cfm MECHANICAL
BREMRECEPT ch &Outlets ELECTRICAL
BSEISMICRE 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