03050058 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRWCTOR�INFORN. ATIpN �
WING ADDRESS: ATLAS HEATING PERMIT No 03050058
OWNER'S NAME: 155 SAN LAZARO AVE "9713/2003
RRERA RUDOLFO
ANE: (408) 739-0516 SANITARY NO. CONTROL NO.
ARCHITER/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
L O o LICENSED CONTRACTOR'S DECLARATION Job Description
w C 1 thereby affum that 1 am licensed under pmvisions of Chapter 9(commencing P
pr wrath Section 7")of Division 3 of de Business and Pmfcssion Code.aed my licoruo is
mfull fortndcIT eaZo 14(05 � / FURNACE REPLACEMENT .
S„°{? License Class Lic.g
n�n Dow d'1' Contractor
�''' AR CHITECT'S DECLARATION FOaces a,ALE
1 understand nd my plans shall used u rdu�l
public reco
s we
Hu
;LLQ' Licensed Profcuionl
O OWNER-BUILDER DECLARATION Mqy 2 9 2003
I homby affirm Thal I am exempt from We Convector's License Law for the
O O following Mason.(SOction RD 1.5,Business and Profusion Code:My city or county
$ which rc4umes a i mmit to construct.alter improve,demolish,or repair any A.M.
F i prior to its issuance,also requite the applicant forsuch permit to file a signed statement
that M is licensed purmam to We provision of dm Contractor's License law(Chapter 9 Sq.Ft. Floor Area 'on
afs $ (commencing with Section 7")of Division 3 of 003 Business and Professions Code)or
_
that he is exempt therefrom and the buss for the alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 @&ISTi-fli crO 0 OType
not more than fin hundred dollars($560). Occupancy Y YP
0 I.as comer of the property,or my employees with wage As their sole cempenatinn,
will do the work.and the Structure is not intended OcolEredf Wash.(See 7044,Business
and Profevion Code:The C.ra scmr's License Law does not apply w an owner of 303 - ROUGH lillHAN I AL ns
property who builds ar iceproses Merton,and who donsuch warthim elforthrough his
Own employee,provided thatsach Improvements am not intended proffered rot Aske If. 304 — ROUGH ELECTRICAL
however.the building or improvement is mid within one year of completion,the owner-
builder will have the burden of proving Nat he did tet Mid or improve for purpose of 505 - FINAL ELECTRI CAL
.in
l 507 - FINAL PLUMBING
0 1,u owner of the property am exclusively contracting with licensed contractors to
construct the Project(Sec.1044,Business and Profession Cade:)The Contractor's U. 508 — FINAL MECHANICAL
cense law dean not apply to an owner of property who Wilds or improves Woman.and
who contracts for such projects with a comractor(s)licensed pursuant to the Conusomes
License law.
0 1 am exempt under Sec. ,B&P C for this tenon
1;C1
wner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under petully of perjury oro of the following declaration:
1 haw and will maintain a Cetu fcam of Consent calf-insure for Worker's Comyom
.it...a Provided for by Section 3100 of the L Wan Code,for the pertarmantt of the
rt for whim this parmit Is issued.
1 haw and will maintain Worker's Compensation Insurance,u required by Section
00 of the Labor Code.fm the performance of the work for which this permit is issued.
y Workers Comp nn otho t lnsurace carrier and Policy number art:mer. 5 �h�� pdb NU 9_�5/�7
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thu section need trot W completed ifft Permit is foronc hundred dollars(SIM)
or less)
I certify that in the performance of We work for which this Permit u issued,I ahall not
employ any person in my mmMr ao As in become subject to die WerketS Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT.If,afmr making Nu Cenifnte of Exemption,you should
become subject to We Worker's Compensation provisions of the labor Choc,you muss
.JO foMwith comply with such provision or Nis permiuhall W dcemod revoked.
Z�y CONSTRUCTION LENDING AGENCY
'f•' Ihereby affirm that Nem is comtmcuon lending agency for the ianfurmame of
!Y the wart for which this Permit is issued(Sec.309'f,Civ.C.)
D]Q lender's Name
=z Lender's Address
U Q I ccnify that I haw read this application W sem Nat the own information is
PconcpL I agree to comply with all city and county ordinances and sate laws totaling to
�U building construction.and hereby authonm repraenativa of this city to ceder upon the
shove-monurned property for inspectioneues purposes
F y (We)acme to ave,indemnify and keep notion Bte City of Cupcnino against
rq incmivauence f thocraning expenses which may in any way ettrue againl.ssid City /
(�z AcPLICAT UNDERSTANDS
of Nupctmit. Issued by: Dale
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N PO{{{NNNTTT
SOURCE fApphc T(DK; n s� /
EGUL
-b�C�li-%lL/-^ Date Re-roofs
Signature of ApplicanJCantracl Date
HAZAR US MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous reasons]
az dcfncd by the Cupertino Municipal Code.Chapter 9.12 and the Health and Safety
ale,Scmian zsvz(a)?
oyes aa6-- All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants As defined by We Bay AMA Air Quality Management all new materials for inspection.
7d-.
trict? 14"
❑Yes
I have mad the harardoux materials requirements under Chapter 6.95 ofthe Califor-
Health&Safety Cors.Seem—25505,25533 and 25534.1 Undimmed thea if the Wilding
tet ewmn0y hov nt,that it u my resp retWility to notify the becupat of the
uircmcna c s met peon uacc ofa Ccrtifica¢of Oc p cy.
�10 Signature of Applicant Date
owner rr arthorivy�sgcnt ///D,mI All roof coverings to be Class"B"or better
CITY OF CUPERTINO
�d FURNACE/AC D 3
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Az LF�F
Owner's Name: Phone#:
t.� ? /0 9 z�
Contractor: Phone: License#:
t�acc , qO8- ) -0516 L{6 5 26 6
Contact: v Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ ls`floor ❑ 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 Project: Type of Construction: Occupancy group:
c- 2 • D-U
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
A licable Fee ID Fee Descri tion Fee Group
=-RE
Ener BUILDING
Relocation of Furnace MECHANICAL
A/C Unit> 10,000 cfm MECHANICAL
A/C Units <= 10, 000 cfm MECHANICAL
Rec tl, Switch & Outlets ELECTRICAL
Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
J MPERMrl FEE Mech Permit Issuance MECHANICAL
e PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING