030900881
CI'CY OR CUPIR'PINO
BUILDING DIVISION PERMIT
CONI RACTOR INFORMATION ;*
BUILDING ADDRESS :
WY
ATLAS HEATING
P[RMIT%3O9O088
WNR NAM FPWARD
155 SAN LAZARO AVE
PERMIT ISSUE DATE
DNE:
(408)739-0516
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR 'SDECLARATION
Job Description
rChar
1 hereby efhrm that 1 am licensed unJer, provisions of Chaplcr Y (commencing
With Sec,ion]DRy.1' Division 3 ofthc Busincsvandi r ioiynxfycd been. is
In full force and en¢ /(OO
LicenseClasa �' zo ase.
A -ON A/C
4`
Da/'r-�Q m f '—"'
CT`S DECLARATION
As
I understand my plans shall he used as public records
shall
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that am esempl form the Contractor's License Law far the
following reason. (Secliun 71131.5. Business and Pmfeasions Code: Any city or county
which requires a pelmil to construct, alter, improve, demolish. or repair any structure
prior h, its issuance, also inquires the applicant for such permitto rile a signed smmmenl
that he is licensed pursuanuo,he pmvisimvs of the Cmuractur's Liernse Law (Charters)
Sq. Ft. Floor Area
Valuation
(commencing with Section IIIDO of Division 3 of the Business and Professions Codc) or
that he is exempt therefrom and One basis for the alleged exemption. Any vinlminn of
35619002.00
Semon 7831.5 by any applicant for a permit subjects the applicant to a civil penalty of
ApN Number
Occupancy Type
not more than five hundred dollars ($5(m.
- - --
- P Y -'-- -
1, as owner of the progeny, or on, emplayces with wages as their.mlc confirmation,
will do the work, and the structure is not intended or offered for sale (Sec. ]Dad, Business
and Pmfcuions Code: The Contexemr's License Law dans not apply to an owner of
ections
proPeny who builds or improves thereon, and who docs such work himseffonbmugh his
303 - ROUGH ME RANI AL
own employees, provided that such imprnvcmearsare not intended or offered for sale. If.
304 — ROUGH ELECTRICAL
howeser, the building or improvement is mid within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for purpose of
505 - FINAL ELECTRICAL
sale.).
507 — FINAL PLUMBING
❑ 1. as Owner or the prapany am exclusively contracting wird licensed contractors to
eallalrun the Project (Sec.]Oad, Business and Profession. Code:) The Contractors Lt.
508 - FINAL MECHANICAL
cense Law does not apply to an owner of prop[" who Wilds or improves thereon, and
who contracts for such pmjecta with a contractors) licensed pursuam to the Contractor'a
License Law.
C I am exempt under Sec. B& P C for this
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby effirm unJer, penally of perjury one of the following declamations:
-
haveandwillmainwinaaniBeateofGnmmrtla,elf-insareforWorkr'sCoapen-
APR 14 2004
urian, as provided for by Section 37W of the Labor Care. for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as requited by Section
n �t'e
BUILDING
]BB of the labor Code, rot But performance of the work for which this permit is issued.
1� L� ®'��
My Worke/5's Compensation Insurance carrier and Policynumber
mbber amp:
�•-�
Curter:^ 4 L6L aWit a Policy No.: ,l I Z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(IDismc,ion need not he completed if Ile, permit is for one hundred dollars (S IRB
Jr less)
1 ccnify 0.1 1. the pclfarmanee of the work for which this permit is issued, I mail not
employ any person in any manner m u to became subject o the Workers Compensation
Laws of California, Date
Applicant
NOTICE TO APPLICANT: Ir, after making this Cenifcale or Exemption, you should
become subject to the Workers Compensation provisions of the Lffior Code, you mus,
forlhwi U1 LnmP1Y with such provisions or his permll shall to deemed resulted.
CONSTRUCTION LENDING AGENCY
1 hereby sffirm that here is a construction lending agency Ior the performance or
Jus .,it for which Nis permit is issued (Sec. 3BW7, Civ, Cd
Lender's Name
Lender's Address
1 terrify that l have read this apppii and smc that Bic above information is
rtes. 1 agree to comply with all city and county ordinances and imus laws relating to
building construction. and hereby awhoriae expresrobluise of this city to enter upon the
aM1ovc-mc r) nedagree to trynow, for inspection an keep ha.
(We) agree ro save, indemnify and keep harmless the City of Cupertino against
liabilhies.judgmcns, cos and cspcue hicM1 may in any way accrue agamv said Ciey
in conscquenec of the gof,hi
APPWCANT N TAN( Dswl COMP ITH RLL NONPOINT
Issued by: Date
SOURCE RE
Re -roofs
/r o]
Signamrc of ApplicaDam
HAZARDOUS
HAZARDOUS MATERIArfa DISCLOSURE
Type of Roof
Will the void or handle
forum Wal
occur.Chapter
a Cu,nan,of
as defined by the Cupcnino Municipal Code. Chapter 9.12, and the ficahh and Safety
Co Health and
Code, Section 25532(.)? ]
All roofs shall be inspected prior to an roofing material being installed.❑Yea
Will the applicant or rumrc building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
it ha'ratdous air contaminates az J by the Bay Arca Air Quality Ma..'arrm
all new materials for inspection. -
Dislricl?
❑Yes C1 NO
I have mad the haaandous materials requiremems under Chapter 6.95 of,he Cali for -
nialicalI&Sacy Qle. Sections 25505 33 and 255,V. I understand Nal if the building
d(Iet not t'urt[nll atCnan y SpJ Ilybrlidfy BX YYpa(Il n(Ne
tr m
requirem a s Ip rI Bmrwra➢cy
Signature of Applicant Date
All roof coverings to be Class "B” or better
Owner authorised agent D„e
I�
1
41
CITY Of
CUPERTINO
CITY OF CUPERTINO
FURNACE/AC
PERMIT APPLICATION FORM
nd�
030 �0 C) sE
APN # 3 SJ �
Building Address: 1
�/S 3�r'
BREMFURN
Owner's Name: C
Phone #:
Contr or: Phone:License
1:3 -0,S 6
#:
6 s z 6
Phone
Contact: ��
Cupertino $us ers License #:
*��'S
`f2
Building Permit'Info:
Rec tl, Switch & Outlets
Bldg ❑ Elect ❑ Plumb ❑
Mech
Job Description:. QYI.. a /C — 6 -/ Or _ t�
m ve,
EPERMITFEE
Elec Permit Issuance
Residential ❑ Commercial ❑
MPERMITFEE
For Residential Installations:
MECHANICAL
Attic Cl 1" floor ❑ 2nd floor ❑
Plumbing Permit Issue
Adhere to min set back requirement [I
BPERMFEE
'For Commercial Installations:
BUILDING
Replacement same weight ❑ Additional weight (structural calcs) ❑
Plan Check Fee
Structural Calculations required for new installation ❑
BUSLIC
New installation Planning Approval Required ❑
BUILDING
Cost, ofProject: ojType of Construction:
L+a
Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
A i i ble
Fee TD
RvP Tlacrrinfinn
C-- c_,..._.
BENERGY
Energy
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit> 10,000cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfm
MECHANICAL
t BREMRECEPT
Rec tl, 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
�, �/i V. /