03030144 CITY OF CUPERTINO
mv
BUILDING DIVISION PERMIT �� CT.10 IN ATIONN
BUILDINGADDRESS: ATLAS HEATING PERMIT NO.
�632 ng r-Q9 PR
OWNER'S NAME: 155 SAN LAZARO AVE PERMIT ISSn A
g; SANITARY N9.3 OL NO.
(408) 739-0516
ARCHITECT/ENGINEER: BUILDINO PERMITINFO
BLDG ELECT PLUMB MECH
p o tom ' o 0
+I G0 LICENSED CONTRACT'OR'S DECLARATION Job Description
-M '
1 hereby apane that l em licensed under provisions of Chapmr 9(commencing with Section 7010)mf Division Sof the Business and Profculons Cade,and my license is
n�qN is f"°ron`siy er"2-C Lm M1 ZG Co FURNACE-110 , 000 000 BTU FINA .E13
ZJ(: License Cl
Dao o/�- conuacwr
ARCHI'IF.CTS DECLARAT N ^�
I underarm v}
maund my plans ll he used as public records MAY 0 1 ZOOJ
p
Licensed Professional
5G ,
OWNER-exempt fr DECLARATION
apm 1 hmatc affirm Net 11. exempt(ruse the Camns,Co License Law for the BUILDING
1 1'1 DI fk,�y
Ka o following rtosnn.(SCNun 71171.3,Business and Professinm Crede:Any city ter county _ V L 1 V G
$ which requires a Permit to eormonct,alar,improve,demolish,or report any stmmum
FZ prior w in Issuance,also rent the applicant(Or such permit to file Asigned staamem
{Fpthat he is licensed pursuant to the previsions flhe Contractor's LIccmLaw w(Clapter 9 Sq.Ft. Floor Area $��ly
Nn on
65$ (eommeneIng with Section 7000)of Division 3 of Ne Eusimmond Professions Code)or
he Isesempl Nemlwm and Ne basis for Ne alleged enmption.Any vi,dation o!
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of
not more than five hundred dollars(ML 3YgT eT 00 Occupancy Type
❑1,as owner of the pmpcny,or my employees with wages their sole cempenutlon, -
willdotheworkendtheswcwreisnotIntendedoroffeed fonafe(Sec.70",Business
end Profusions Code:The Contractor's Lianas Law docs not apply 0 an owner of 301 — ROUGH )&40MN3W ctions
property who builds of improves thereon,and whodoessuchwork himselfor through his 303 - ROUGH MECHANICAL
Own employees,provided that such Improvements arc not ntended cronered foruk.If. 3O�I — ROUGH ELECTRICAL
however,the building or lmpmm
vaem iasold within one you of completion,the tremor-
builder will have Iles burden of proving that he did nut build or Improve for purpose of 505 - FINAL ELECTRICAL
❑1,as net of the protocol,am exclusively contracting with licensed conuecton to 507 ,—, FINAL PLUMBING
convect the pmjcct(Sec.70".Business and Professions Codi no Conlnetm'a Lt. .SOS — FINAL MECHANICAL
cense Law does not apply to an owner of property who build,or Improves Hereon,and ..
who contacts for such projects with a convector(s)11unsed pursuant to the Contractor's
License Lew.
❑Tun exempt under Sec. .B R P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
Ihereby affirm under penalty of perjury one ofthe following declarations:
have and will maintain a CcolficamofConsent to self-Insure for Worker's Compere- '
on,As provided for by Section 3700 of the Labor Code,for the Performance of the
work for which this permit is Issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
7 of the labor Code,for the pcdormmce of the work for which this permit is Issued.
My
ompe�ys,,tion lnwnnce c'sjrtiennd Polic;•number am: -
Carrler:�i((Af'IO/r"44r+PolityNo.. C�fCa3Sl97
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secilms need not becompinmd if the permit Is fruo echundreddollm(SIOD)
or[Co..) '
1 certify that In the performance of the work for which this permit is issued,I Nall not
employ any person In any manner an As to become subject 0 the WafkCW ComPeosaOOn -
laws of California.Dam -
Applicant
NOTICE TO APPLICANT:If,alter meting this Cenificne or Exemption,you should .
become subject An the Worker's ComP oucown previsions of me Labor Code,you must
�z forthwith comply with such provisions or this permit a hall hes tleomed revakod. -
Z� CONSTRUCTION LENDING AGENCY - -
[—i I hereby affirm mat men is a cCn mctinn lending agency fat the performance of
C s7 me work for which this permit is Issued(Ste.3097,Civ,C.)
QLender'.No
7 z Lender',Address
U C 1 certify Bat I hove read this application end sus sen the above information is
IL Ecorrect.I agree to comply with All city and county ordinance,and sus laws mating to
C, building convection,and hereby aumarim representatives of this city to color upon the
4k7 shove-mcntionrd property for inspection purposes.
(We)agree tosaw.indemnify and keep humlo s the City of Cupenioo against
V In
v) IIabllideajudgmemts,cast,and expenses which may In any way accwe egalntsald City
APPLICANT consequence I
ANTUNDERSTANDSor the granting of IAND WILL COMPLY WITH ALL NO -P NT Issued by: Date
SOURCE REGULATIONS. rl
03 Re-roofs
HAZARDOUS
Signnofurt ApplicaDoll
HAZARDOO US MATERI LS DISCLOSURE Type Of ROOF
WIII that applicant or future bulling occupant store or and the
hvudous materia)
As defined by the Cupertino Municipal Code.Cheplor 9.13,end the HcaIN and Safety
Id
lc,Scotian 25532(a)7 li+rb All roofs shall be inspected prior to any roofing material being installed.
Yes
Wilt 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 hauNnua err conmm'emia as domed by me Bay Am,Air Quality Management all new materials for inspection.
suin7
❑Yes /
I have mad the hanrdomm nerlels requirements under Chapter 6.95 of the Callfor,
ebolam, myrtonohee not curtendy ho ant mat h is an rcaponslbillty m nndly t oeeupt M meuircmcn mustbc tprinrmisw areceninnatraj, ea er . Signature of Applicant Date
owner nr.mm�rivndapc D,13 All roof coverings to be Class"B"or better