03110132 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION '
BUILDING ADDRESS: ATLAS HEATING PERMITNUO 3 110 13 2
10195 POTTERS HATCH
OWNER'S NAME: PERMIT ISSUE DATE
IdIhICHARD LIEBERMAN 155 SAN LAZARO AVE 11/21/2003
40,NE: SANITARY NO. CONTROL NO.
(408) 739-0516
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� E t� is
iO, LICENSED CONTRACTOR'S DECLARATION lobDescri Ilan
ee U 1 hereby Affirm that 1 am licensed under Provisions of Chapter 9(commencing P
2;DO with Section )afDivision3oINCBusinessand ProfcsiansCode.endmylicenuis p/� p
.;5i in fullfnrtea alta - FURNACE REPLACEMENT F'N/"'�LGD
q z License C `'�
Data GUnUACInf
eqq As&hallECTSDECLAR or NOV 2 4 2003
`Z IundcrstanJ my plans shallbeuuJu public records
so.
pt; Licensed Pmfesaioal '
5 OWNER-BUILDER DECLARATION BUILDING
I I hereby affirm that 1 am exempt from the Contractors License Law lar the
❑D following nason.(Section 7113 1.5,Business and Pm(essions Code:Any city to county
$ which requires a permit to construct,alar,improve,demolish,or repair any structure $1000
prior,its issmome.alsorequire da.poiont for mch permit,Ela asig.d,uument
pp < that he is licensed pursuant to the provisions,of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
d�D (commencing with Section 7")of Division 3 of the Business and Professions Code)or
y
at he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for A permit subjects to applicant to acivil Penalty of
not mora than Eva hundred dollar,(SSW). e Occupancy Type
❑I,As owner of the pmperty,or my employees with wages As their sets compensation,
will do the work,and Ne structure is not intended or offered for dale(Sec.1D44,BuMneu
And Professions Code:The Contractor's License Law does not apply to an owner of Required IDapeCIIODS
property who builds or improve,thereon,and who does.wh work himself or through his
own employee,provided that such improvements are not intended or offered for talc.IL
however,the building or improvement is sold within one year of completion,the owner.
builder will have Ne burden of proving Nat he did opt Wild er improve for purpose of
sale)
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the pmjem(Sec.8114,Business;and Professions Code:)The Conuac,r's U. .
cense Law doe not apply to an ownw of property who Wilds or improves due on,and,
who cpmnma for such projects with a contractor(s)licensed pursuant o the Contractors
Lmse Law.
❑ sun exempt under Be.. ,B&PC for this rcuun
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRmn under penalty of perjury one of the following declarations:
I have and will maintain a Cenif ata of Consent to self-inmm for Workers Compere
1c,
ian,u provided for by Section 37M of the IAbw Code,for be Ndarmmre.(,k
rk for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,u requited by Section -
BB of the labor Code,for the Performance of the work for which this pefmit is Issued.
Wmkr Compea alihm Insteacanter and Policy nMe Poll a.: 1 4�•r
CERTIFICP 'OF EK PUBIC FROM WORKERS'
CI MPENSATION INSURANCE
(fhb section need not W comPleted if the permit Is for one hundred dollars($100)
nr less.)
I ecnify that in the orrarmance of the work for which this Permit is issued.l shall Out
employ any person in any manner an as,become subject to the Workera Compensallon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificate of Exemption,you should
become object to the Worker's Compensation provisions of the LANs Cade,you must
., O forthwith comply with such provisions or this permit shall be deemed hawked.
Z M CONSTRUCTION LENDING AGENCY
I hereby vRhm that tberc its construction Tenting agency for he Performance of (.....�
x the work,which this permit is Wood(SAO.3091.Civ.C.)
:3.Q Lender's Name
=z Lender's Actuates
U p 1 cenify Nat 1 have read this application and sate that the above information is
IL F comet.I agree to comply with all city and county ordinances and sou taws relating to
0 building construction,and hereby authorise repachoadws of this city to enter upon tW
D.1 above-mentioned intercity for inspection pwTwes.
gy (We)Agree to sacs,indemnify and keep harmleu the City of Cupertino against
rag liabilities,)udgrecna:costs and expenses which may in any way same against mid City 1!//
UZ in conseyuencc of the granting of this Permit. I
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC LAT N
l- l d Re-roofs
S alum O ApplicantlContna r Date
HAZARD S MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future Wilding occupant Shme orhandle havardoa material
as dellned by the Cupertino Municipal Code.Chapter 9.12,and the Hestia and Safety
ate, p Yfolss33(a)]
ex h'INa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building pappant ha equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
it h/ardnus air contaminants as defined by the Bay Area Air Quality Management
arin7 all new materials for inspection.
❑Ya �No
1 have real the Wardous materials requirements under Chapter 6.95 of the Calirm.
Iia Health&Safety Code,Sections 25515.25533 and 25534.1 underatand that if not Wilting
Jars not umcnty hamatenegt.thvt it is my rca ity 0Badly tbe aeupant of the
require w rich tWmetpdornrissuanccaf nifipefor culancyy. Signature ofApplicant Dale
f 6111 {�
nef pr apmarimd avant - Dare All roof coverings to be Class "B" or better
CITY OF CUPERTINQ.
FURNACE /AC o3 Z_
Ciro or
CUPEI,TINO PERMIT APPLICATION FORM
APN # 3`- 2
- :35 - 053 Date:
Building Address.-
Owner'�alDmq-6
ddress:Owner'�aDmq-6 L+ Y� � Phone
contractor; Li•:ense
d y
Contact: P: on'
Applicant/Contractor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: nn Q
Residential: P�`r r i Y(� � Commerc al:
Sq.Ft. Floor Area: $/3q.Ft.:
Arch itect/Engineer: Vnlua ' n:
• Type of Construction: O:cu c GOr
Qt if ✓✓
A li a le Fee ID Fee Descri t_i m Fee Gr up
BENERGY Ener _ BUILIDNG
BREMFURN Relocation of Furnaca MECHANICAL
BREMACOVER A/C Unit > 10,000 chn 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 Issuanc MECHANICAL
PPERMITFEE Plumbing Permit Iss' e PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
0 a-o