01070053 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: It PERMIT NO.
10170 MACADAM LN ATLAS HEATING 01070053
APPLICATION SPA DATE
o9`8kY"A8DDY 155 SAN LAZARd )�VE 07/13/2001
W'HONEi SANITARY NO CONTROL NO.
S, If (408) 739-0516
a ex Z ARCHITECTIENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
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z LICENSED CON7RAcroR'S DECLARATION Job Description
ir
�Q I family affirm that I ran licensed made,powisimi, fCW,um 9(,varnmencia, ADD AIR CONDITIONER.
, ) f r
1- with Section 7")ofDivision 3 ofthe Business andprvfia�I*Lb�Chile,and my ficense
is in full forecander at.
at Or c be, 'it a
ex. ,a
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�; i vem". I"A W
ARCHITECT'S DECLARATION
i�0 1 undchravil my plar%quill the used ans public mccurch;
Oc
,_.O Licensed Professional
OWNER-BUILDER DECLARATION
I hereby liffin. bar I in.exempt from the Contractor's License Law for the I
following mason (Section 703 1��Bmines,and Prefiessiter;Cosh:Any city or county $3500
5 a which requires a Permit to construct.alter.improve.deandish.or repair any structure
11, c, prior lu its i�srrmcc.alsorm,ims thicapplicant forsuch enou atflic a signecixtatermint
(commencing with Section 7000)of Division 3 of the Business ad Professionals Codc) :3 6'�9101114Acpr-66ra:) Valuation
or that he is clent mirefrom and the basis for the allijid mimperm Any'folminn
of Section 7031.5 by any applicant fell a Permit subjects the applicant to a civil penalty
of no,motre than file hundred dollars(S5M) 3 0 1APN K006H PLUMBIN� Occupancy Type
0 1.as owner of the propshi or my employees with Wages as,their sole compensation. 3 03 - ROUGH MECHAN AL
will On the ol and the surfacture ix not intended or offered for sale sea.7044.
flu;inass and Professions Code The Contractors License"a%costs not apply to an 3 04 - ROUGH EIIEqLT&dQVactions:
ow at,of property Who Wild,or inr,wmv.� he..,and who does such work himself 501 - FINAL ELECTRICAL ENERGY
Or through his own car,idcd Ill., .On irn,rio�rrmrr,act a.,intended Or
-othered for sale.If.however.(be Inuilifing or improvement is sold width One Year Of 502 FINAL PLUMBING ENERGY
completion,the owner-tarlder will ban file Wunden of proving that Im did not Wild or
n,m,c for,mr,il't of sale.). 503 FINAL MECHANICAL ENERGY
505 FINAL ELECTRICAL
C 1.as owner of me properly.am exclusively contracting with licensed conscracturs to
clacroal the Project(SO,.7()OW.Bmue,, ad Profession,Code)The Cmememir, 507 FINAL PLUMBING
License Law dox,hot apply 1.an minter of property who Wild,or un,vi them...
and who contracts for such portects with a cmaraclarls)licensed purlart to the 508--- —F-INAL MECHANICAL
Ciumenami'a License Law. . I
0 1 am exempt under Sec. A It P C for an.reason
o Oam;, Date
WORKER'S COMPENSATION DECLARATION
I hereby difirm under crally of per-J."y one it me following dealreationx. FINALED
0 1 fare and ill mairearn'.Cartifi,ane of Chosen,to self-in..a far Worker
Compensation. as provided for by Section 37W of me Lathm, Code. for the
Performance of the work for which thispillit i.s issued NOV 0 6 2001
0 1 have and ill maintain Worker's C I mr,sersation In,I mance, required by Section
3700 mdue Labor Code,((it the performance of the work for which this permit is
i"utd.M k,,, ,rsr�lm?lsio;�ancc ciurier and Policy mummer art: BUILDING e
Carl Pot No.:
it
C 71 AnUN OF EXbMFflUN rKUM WQRKERS
COMPENSATION INSURANCE.' ------
I INL t-1,'$I,
rrbi�x,estion need not fit compurk if the Permit is for one hundred d.11.,
SI 00)or less
'Iterthy that in ir',perlo6faccoul Ork'f.;.sOh this,eirmt is issued.I
'hill �m employ say ,.a in any mutual m as 1.�a?mcx.bjc.1. he Workers'
cmmereanion 1-aw,of C.hmarmn Dale
Appl cant --------
Z become subject to tire Worker s Compensation provisions of tile Labor Code.you anno
forthwith cumply with such Provisions or this permit�hall M descresed havolod,
�'CONSTRUcrjoli LENDING AGENCY
I hereby affirm that them is a ammuction leading agency for the onformancle
Of he work tur wh tch ruixpermit ix k��ed(Sec.3097.Civ C.i
Lemic,x Name
Z m
Litude,*,Add
U 0
I ecilify that I have mad this application and state that the abseve information is
correct,I firm to compil with all city and county ordinances and state laws elating
U a Wridin,,rusimadim.and rarely sort �mha,m,mori,,,,
of It,city to enter a,mi
W thm dreve-involumud roped,for i
ar,catual surfavoc'.
(NVI.,rmrrohcJrd,mmf a
�y
y
0.�� lint, %,rad xp` which may in any way .'arml'aid,
Cry it i a n',
a
APP:��J'CAN NDERSTANDS AAAW LL COMPLY WITHAL NON
z f lh'c in "hum"
SOURC I LATJV/V Issued by: Date
ut Z9=±
Ill Dale Re-roofs
am"' r0
HAIII IS L 1,11]i DISCLOSURE
Will th,alpliche r foure �,thccpffn atr lamulle havent mocrud Type of Roof,
pv,�io
a M u r l tlb�,�Id 0. W,:lsru,
declined by the C, mcdma Heallh and Safety 7
Code Section M532(to? I
' : C installed.,
0 ye,
-All.roofs.shall be-inspected prior.to any roofing material.bein
an inspection,
Will the if,p,licamor future Wildingrecuport use equipment ordevicas which If a roof is installed without first obtaining I agree t6 remove
clon arandons air couraminars as delined by the Bay Area Air Quality Management
Di,f,b , all new materials for inspection. Applicant understands and will comply with
Ys, ON. all non-point source regulations.
I halt mad de, flat us in Hill,mi,inernam,end,,Charter 6.95 Of'he
California Health&Safety Code.S r us 25505.25533 and 25534.1 understand that
Ifthe hoildin,does am mm 1,1. To I hal it is my responsibility to roily the
accurate, fp requirchromis whil .,t be met print 1.i....nc�,11.cfphficlimidf Date
0 nph
Signature of Applicant
A 0/9/16)
All roof coverings to be Class"B"or better
Owner or authourred agent Date
OFFICE