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05020100 CITY OF CUPERTINO r BUILDING DIVISION PERMIT CONTRACTOR INFORMATIONR BUILDING ADDRESS: ATLAS HEATING PERMIT N`65020100 OWNER'S NAME: PERMIT ISSUE DATE ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 woo LICENSED CONTRACTOR'S DECLARATION Job Description WV G I kmaffirm by but I am licvvcd iu under pmvons of Chapter 9(commencing U wiub Section 90(10)of Division 3 of NC Business and Professions Cade and my license is e o nnoreeameflq / �/3�Z REPLACE FURNACE z g n License ;;Ri Lie N z—c Dam Lie#c n f',' ARCHITECTS DECLARATION - jw1 unhe u dcrand my plans shall used public records U ;6 C r Licensed Pmfcssional 3 OWNER-BUILDER DECLARATION I 1 hereby xlfirm Nat I am exempt from be Contractor's License Law for the 00 following mann.(Section 703 L5.Business and Pmfewimn Code:Any city or county rts which.quia permit to conewd al¢q improve,demolish,or repair any..seem. Fly prior to its isaumm.alsorequires nheapplicam Inrsuch permiuo fileasigned settlement �0 Nat he is licensed pursuant to nhcprevisions of be Contractor's Lier.law(Chapter,9 Sq. Ft.Floor Area Valuation set- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or E59 that he is eastern therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of n 3 7F�fli131(I�J3e�O Occupancy not more Nan five hundred dollars(S500). P Y Type 0 1,u owner orthe pmpmy,or my employees with wages u theb mle compenudun, will do the work,and theswcture is;Out intended oroRered for sale(Sec.70aa,Business and Professors Cade:The Contractor's License Law does not apply m an owner of Required Inspections property who builds orimproves thereon,and who does suehwork himselforduough his Who ho-employea.p Wilding or improvement vemeuch ntproold wit in mue ear o(c or offered for sale. r- h Aide, mebuildingorimprovementismidwithin am year o(completion. will have the burden of proving WI he did not build or improve for puryose of nk.). ❑1,as owner of be pm.74)4.B exclusively contracting with licensed contractors i- `�j . come,La me es not apply to an Business and Professions Cade:)The Contrutor. nd V Li- come,Intra dors not applyje an owner of property who builds or improves Normo,and O whocontractsLis for such projects wise acontractor(s)licensed purwam m the Conuacmh LKCM1ti Law. ❑lam exempt undo Sep ,B&PCfor his won Owner Dam WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain aCcr4finm of Continuo self-insure for Worker's Compcn- IC3377�'W ion,u provided for by Section 37M of the labor Code.for me performance of me rk for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,u inquired by Section of me Labor Cade.for me pmformuce of the work far which this permit is issued. y Worke ore natio InsurmecarierandPolkynumn�b�erraa�e"��)�/��/�rtier. ( Y Policy No.:�[ CERTIFICATED EXEMPTIONFROMWORKERS' COMPENSATION INSURANCE (This tictim recd not he complecd Ironic permit is fororc hundred dollars(SIM) m less) 1 certify mot in be pc,fnmaosit of the work for which this permit is issued.I shall not employ any person in any manner m as In hecome si b)ectI.the Workers'Camrensatimi Laws of California.Dam Applicata NOTICE TO APPLICANT:If.after making this Certificate or Exemption.you should bemm,subject to the Worker's Compensation provisions of be labor Code,you most .Jz foMwi on comply with such provisions or this perato&hall he deemed revoked. zO CONSTRUCTION LENDING AGENCY 'rte I hereby aRrm mat them is a construction lending agency for be Performance of C the work for which this permit is issued(Sec.3097,Co.C.) ALender's Name IL z Lender's Add. U Q 1 certify Net 1 have mad this application and state than be above information is . L. P concet.1 agree to empty with all city and county ordinances and sum laws mtadng to 0 building construction.and hereby autioneempre&enatives of this city an enter upon be r G above mentioned property for instruction purposes. (We)agree to now.indemnify and keep hannkss be City of Cupertino against F" h liabilities,judgmen¢costs and cxpcues which may in any way scenic against mid City f>Z to consequence of the in of this perm'. APPLICANT UNDERSTANDS AND 1 L COMPLY WITH ALL NON-POINT Issued by: 60Date {)�,) S URCE ULATIONS. �� / Re-roofs Sigmaurect Applicam/Conuacm/ - Date HAZARDQUS ATERIALSDISCLOSURE Type of Roof Will the applicant or future wilding Occupant store or handle haosdous material as defined by Oc Cupenim Atari ipal Code.Chapter 9.12,and dm Hcalm and Safety Code. Sermon 25su(a)7 OyesON. All roofs shall be inspected prior to any roofing material being installed. 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 .mit hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection. Distrin7 ❑Yes 0 N I have MW um Waents mamrials requirements under Chapter6.95 oflhe Califon ria Health h SafctyCode Security;75X)5,25533 and 25534.1 undersand duifdic building does non cummly have a mnant�don it is my resporibilay to nauly the meupan of the mai cnkswhich musnhe pnortoiuuanccofeCcruOca juPanc 6 Signature of Applicant Date Owner ar authorned ag I / Dare All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 INUPERTINO Building De artment JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # GENERAL CONTRACTOR: ajlFAX # I am not using any subcontractors: d4z B'fji/" �5 SiDate Please check applicable subcontractors and com let the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date Now CITY OF CUPERTINO 1,��`" FURNACE /AC v S'' ° 21Gry CITYOF ® CUPERTINO PERMIT APPLICATION FORM APN # 3Date: Z JS�^� O J �5—'� 3 -�co5 Building Address: Owner'tName: PhoneLContra '4o ml,0 License#/ Og (Q o l3 Cont• P one Applicant/Contractor: Building Permit Info: Bldg Elect Plumb Mech Job Description: Residential: �� (y-)0.(_Q. Commercial: Sq.Ft. Floor Area: $/Sq.Ft.: Architect/Engineer: Valuation: Type of Construction: Occupancy Group: Qty. if A licable Fee ID Fee Description Fee Group BENERGY --Energy BUILIDNG BREMFURN Relocation of Furnace MECHANICAL BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL BSEISMICRE Seismic Fee Res BUILIDNG EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING BPERMFEE Bldg Permit Fees BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BUSLIC Business License BUILIDNG