03060150 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONT RAQ401k INFORMATION
A
BUILDING ADDRESS: ATLAS HEATING PERMIT NO 03060150
l
ANE
OWNER'S NAME: 155 SAN LAZARO AVE PERMITISSUBDATE
ROBERT KAPUR n Z24/200,;
ONE: (4 0 8) 739-0516 - SANITARY NO. CONTROL N0.
ARCHmIC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 o t�
+00 LICENSED CONTRACTOR'S DECLARATION
w C 1 hereby affirm Thal 1 am licensed under provisions of Chapter, � 9�r,9(commencing Job Description
ZX85 A pg�s
p, with Section7IXMpnf Division Sof the B.amammd Professions and Cmk, my license is 'tea®
in full force andc t �� 2L ( FURNACE/AC INSTALLATION
p0? License Qlazs 0 Lic.N 't
;FO Date CreSuacmr AUG 1 2003
ARCHITECTS DBCLARATION
ee�y I understand my plans shall be usedD,public.,.,its
;WG
St, Licensed Professional - BUILDING
OWNER-BUILDER DECLARATION BUILDING
a f 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
OE fallowing mason.(Section 7031.5.Business and Profemiom Code:Any city or county
C m which requires a permit to construct,elect,improve,demolish,or repair any structure
Prior to its issuance,also requirce the applicant for such permiuo file a signed statement -
010
< that he is licensed pursuant to the provisions of the Contractor'&License Law(Chapter 9 Sq.Ft.Floor Area Valuation
FSC (commencing with Section]OBO)of Division 3 of the Business and Professions Code)or
y, $ Nal he is exempt therefrom and the basis for the alleged exemption.Any violation of 37535046 . 00
Section 7031,5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more than five hundred dollar($500).
❑1,as owner of the property,an my employees with wages as their,sal.compensation,
will do the work,and the structure is not intended or offered formic(Sec.70,14,Business 3 U 1 — ty�
and Pormaione ctod
Code:The Canaanite,License Law m,not apply n a was,or 3 0 3 — ROUGH t100S
property who builds or improves thereon,and who doessuch work himself onhmugh his L
own employees,provided that such improvements am not intended or offered forsale.If, 304 — ROUGH ELECTRICAL
however,me building at improvement is sold within one year of completion,Ne owner
builder will have de burden of proving that he did not build or improve for purpose of 505 FINAL ELECTRICAL
'ale')' 507 - FINAL PLUMBING
O 1.as owner of the property,am exclusively contracting with licensed conuana to 508 - FINAL MECHANICAL
construct the project(Sec.70,11,1.Businessand Professions Code:)The Canuactari Li
cease law docs not apply an an owner of property who build&or Improves demur,and,
who contracts for such projects with a canusetor(s)licensed pursuant to the Conurttor's _
License Law.
O I am exempt under See. .B At P C for this...a
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby aRnm under penally of perjury one of de fallowing declarations: - -
I have and will maintain a Cenifesdo of Consent o selfdnsure for Worker's Comport.
-tion,az provided for by Section 3]00 of.the labor Code,for de Performance of me
work for which this permit is issued.
I ban and will maintain Worker's Compensation Insurance,as required by Section
Wof the tabor Code,for the performance of de work for which mica permit is issued. r
My Work,',Comps ion ln&urmtce artier and Policy num Mr m/a
Cartier�P A 1r.��policy No.:(A.1.1� 435 tq�
CE•R IFICATE OFPXEMPI'ION FA OM WORKERS'
COMPENSATION INSURANCE
mile section need not hecompleted Elite permit is for one hundmddollaa(SIOIB
or less)
1 ecnify Nat in the performance of the work for which this permit is issued.I shall not
employ any Person In any manner an as m become subject to the Workers'Compensation
Laws of California.Dam
Applicant
'NOTICE TO APPLICANT:If,after maki rig this Certificate of Exemption,you should
become subject to the Worker's ComPemution provisions of the Latour Code,you must
Oforthwith comply with such previsions or this Permit had he deemed myriad.
z "'t CONSTRUCTION LENDING AGENCY
j-a .+ 1laeby,Rum that mere is a construction lending agency for the Performance of
Qi de work for which this Permit is issued see.3097,Cis.Q
WM Q Lender's Name s
.7. z Lender's Address
V Q I certify that 1 have read this application and sum that Bae above inromtation I,
U.F correct.1 agree to comply with NI city and county ordinances and sum laws relating to
0building construction,and hereby suborn representatives of this city to enter upon to
Uabove-m.ntiuncd property for inspection Purposes.
(We)same to save,indemni ry and keep harmless the City or Cupcnina against
wIn liabilities,judgments.costs and sapenses which may in any way acem,against avid City
in consequence of the granting of this permit.
APPLICANT U ERSTANDS AfJ�VILL COppPLY WITH ALL N N-POINT Issued by: Date
SOURCERE TIgNS. /, O
/W/'ry►��^_'w`e'� ` )" 11 Re-roofs
Signature fApp— lick amtContncto Detc ff��
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do applicant or future building mcupanl pore or handle Beanke,material
as dcOned by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safely
cad,s.edrnzss3 g+ All roofs shall be inspected prior to an roofing material being❑Yea z( \�Na P P Y g g installed.
S WiB the applicant or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit he...does or crownrnanu az darned by the Bay Area Air Quality Management all new materials for inspection.
❑Yes �No ,�y (%/C�e"�'��
Ihaveread the hvardausm5505, requirements under Chapter uifd.Wilding ��/Q�
does
Scanty Crile,Semen,, but it I25533arWz5534.1 a notil,te the building
dms not currently hovu a mnenL mal it is my responsibility m nntily the aro ant nr do
• requirements which usl!met noon' once ora nifcamofOcean Signature of Applicant Date
Owner i' All roof covering s to be Class "B" or better
tar Dam
t CITY OF CUPERTINO
FURNACE/ACD
CUPEkTINO PERMIT APPLICATION FORM
APN# 7 3 J— C Y / Date:
Building Address:
g l 7,0
Owner's Name:' Phone#:
253 -1/3
C tractor: Phone: License#:
� - d G�.w 739 - b516 X65 z 6
Contact Phone: � Cupertino Busi ess License#:
Building Permit Info:
Bldg ❑ Elect X9 Plumb ❑ Mech
JobDescription: &0 066 B'u
Residen is / Cpmmercial E]
For Residential Installations:
Attic ❑ I" floor ❑ 2nd floor❑
Adhere to min set back requirement❑
or Commercial Installations:
Replacement same weight E] Additional weight (structural calcs) ElStructural Calculations required for new installation ElNew installation Planning Approval Required
Cost,of Project: Type of Construction: Occupancy group:
./O CF/o_'
Strapped El On Platform ElBonded ElSq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
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 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