01100053 CI BUILDING OF UDPERTCNNO
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21115 LAURETTA DR ATLAS HEATING 01100053
OWNER'S NAME: APPLICATION SUB DATE
KISHI YOSHIKO 155 SAN LAZARO AVE 10/09/2001
PHONE: SANITARY NO. CONTROL NO.
(408) 739-0516
O O ARCHITECGENGINEER: BUILDING PERMIT INFO
— BLDG ELECT PLUMB MF.CH
eco
y_ LICENSED CONTRACTOR'S DECLARATION
t❑ 1 tion 7 )of that I am ofth B under provision,P ns of Chapter 9 ad 11 Ging Job Description
wtm with&aron7W0)ofDivision loftheBusinessandPafessions ale.and ylmenu REPLACE 2 FURNACES .
:,a7
is in Toms sad<rce
License Class�_.�L. Lic.k
O d O Date�II 9/_Q_( Comnnor _
7 3 u ARCHITECT'S DECLARATION
O g 1 undersand my plans shall he use es public records
e!iT
S O O Licensed Professional
es OWNER-BUILDER DECLARATION
es I hereby affirm that 1 an
exempt from the Convactor's License law for the
t i a following meant.(Section 7031.5.Business and Professions Code'.Any city or county $4000
❑ which requires.Permit to emearrect.tilen,improve,demolish or repair any.unci
as m laicam t na,a, W 'herplicant for such Permit W o plan stammer
e — that he' lichaval putsi n t ad the provisions of the ConuactMs Licenu Use(Chapter 9 f. t ,tea,,�] r•p(ga y' P Va1LL3L100
(commencingwith sects 7")of Division 3 of the Bosmesa and Preafessions Code) if l;`ct `.13,2-7. :U TO ,"r�.
armed he is exempt themfacm and the basis for the alle6cd xmmpubri,Any violation
fm703L5 �n, aimadr.amitsubjects,m`ephcenm.ervilpdlyo � reman ao301 APN§"R PLUMBIOccupancy Type
01,m owner of the property,or my emtheir ployees with wages m sole compensation, N
CAL
will ne the work,and the structure Is net intended orecaffeendLaw for snot(�y to4a, 3 0 4 — ROUGH E119W7Rd Cd a
Business he work,and the
Cade:The is n t intens License law dor nota 1 to an CLIOIIS'
owner of property Who Wilds or improves thereon,and who does such work himself 5 0 5 - FINAL ELECTRICAL
or through his own employees.provided that such improvements are not intended or __ _
offered far sale.If,however,the Wading or improvement is sold within one year of 507 - FINAL PLUMBING
ora lnion,the mvne,builder will hast the burden of raising that he did not build or
improve fm pin,cunfxale.). 508 - FINAL MECHANICAL
o Los owner of rot Pro peny.am excm.lvely courmetiog with licensed,mantra to
onatrva the project(Sec.701 Business and Pradmid ons Codc:)The Contractor's
License Low does not apply to ea owner of property who Wilds or improves thereon,
.. .. and who contracts for such projects with a contractors)licensed pursuant to me .... _ ....
Cortmetolr License Law.
D l am exempt under Sec. ,R&P C for this rtamn
Own2r Dole
WOR KERS COM PENSATION DECLARATION FIN AF\LED
I hereby uf6m under penalty of perjury are of,he following declarations: G
D 1 base and will maintain a Certificate of Consent to self-insure for Worker's OCT 1 1 2001
Compensation, as provided for by Section 37W of the Labor Code, for the
perfortdnce of the work for which tNs pumit is issued. '
D 1 base and will maintain Worker's Compenmtion Insurance m requited by Scctian BUILDING
37W of the LnWr Cade,for the performance of the work for which this permit ix
issued.My Worker's nmpm.tion Irritative carrier and Policy number are:
Carer of cY No' FROA"�� ft
•' j't .. 4 ATI N F EMPTION f WOR B p
_ COMPENSATION INSURANCE..
Mir section need not he emspined if are permit is for otic hundred dollen
(SIW)orlca.)
I manfy'that in the perform once of the work for which his pe reit is issued,l - _- - ,,., it r -
shall not employ any person in any manner so as to become subject to the Workers'
Compensation Iasis of California.Date
.Applicant -
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should '
became,subject the Workers Compensation Provisions of the LotharCade,you must 1
� tt
forthwith comply with such provisions or this permit shall be dmmed revoked.
Z � CONSTRUCTION LENDING'AGENCY r'
1 herebytff, that there is a<onsuuction lending agency for the performance
W r. of the wort forwhich this am,it is issued(Sec. 97,J0Civ.CJ
(� Lender's Name
_,. ....
5 z Lender's Address
C.7 01 certify that 1 have read this application and...1.that the above information is
W.F soirees.1 agrm to comply with all city and county ordinances and rum laws existing
C,V to Wilding construction,and hereby authorize mprexnatives of this city to enter upon
'w tai are above-mentioned property for inspection purposes.
A4 (Welagm urieve.indemnify end keep harnWcss the Ciry of Cupertino agaimt
V] liabilities,judgments,tuns and expenses which may in any way scare against said
V ^ City in co sequence of the granting this permit. -
r SOU lC UNDERSTANDS AN ILL 1A I Y WITH 107. ;ON-POlrrr Issued by: r Date
of ApplicanU o to for IV\ v1.Daam Re-roofs
Code.Section 7S HAZARDOD A RIALg DISCLOSURE \ Imo( my /� (�"-�j /N
pplicdt or future ad occupant more of handle harardWs material Type of.Roof 'J �-- - ' / f--� / (� v J
d def red by the Cupertino Munimp de,Chapter 9.12,and the Health and Safety
s32(att , „ . .it"s, o il,'
Oyer ❑rya' r •�' fs.shall be inspected..prior.to any.roofing material being.installed.
Will the applicant orfuar<building occupant use equipment car devices which If a roof is installed without first obtaining an inspection;'I'agree to remove
emit menial us air cnnmmionods as d,rncd by the Bay Arca Air Quality Management t
District+ all new materials for inspection. Applicant understands and will comply with
Dyes oNo all non-point source regulations.
x 1 have read the huemoua materials requirements under Chapter 6.95 of Ne
Cnlifomie Health&sufcry Code,Sections 2550525533 and 25534.1 understand that � vim`
if the Wilding docs not currently have a tenant. t itis myasponsibiliry to notify the \
acapant oft requirements wM1ich must W _T
prior to issunnce of a Cr cat
°r Signature of Applicant Date
r euthorizM ngrnt I oat All roof coverings to be Class"B" or better
Of OFFICE