03060148 P ctBUOF
DIVISION I PERMIT CONTRACT0RZ' FORgM TION
BUILDING ADDRESS: ATLAS HEATING PERMIT N0.03060148
L OWNER'SNAME: 155 SAN LAZARO AVE FBRMITISSUEDATE
IF)NE
)NE: (408) 739-0516 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0o LICENSED CONTRACTOR'S DECLARATION Job DesCTIPI100
Z 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
<
All In Section IDk➢Bof Division J of Ne Buaineasend Professions Code.and myliecnsets
mI I one and c1.3 r Lie.e � ADD A/C, 4 TON AND 50 AMP CIRCUIT FOR SHUTOFF
Licenacia(
F Date on
tudelo SWITCH
ARCHITECTS DEC RAST
r; I undenund my plans Mull W used as public menrds
)yu
S0 Licensed Professional
OWNER-BUILDER DECLARATION
y I hash,affirm that I am cacmpt from the Comnmors Litman Lew for the
pO following reason,(section 7031.5,Business and professions Code:Any city or county
5�$ which requires a Permit to construct,alter,improve,Jemnlixh.or repel,any structure
Zi prior or its iauance.also requirestbe applicant forsuch permiuo hula a signed statement
££S< that he is licensed pursuant to Be provisions of the Contracture Llan.law(Chapter 9 Sq.Ft. Floor Area ValulVt ?O310
Y E'� (commencing with Section 7")of Division 3 of the B usiness and Professions Crude)(it v
— that he is exempt deterrent and the basis for the alleged exemption.Any violation of
Section 7031.5 by any Applicant to,Apemd,subjects the applicant to A civil penalty of 3MS1,1Mcr00 Occupancy Type
not more Nan five hundred dollen(ISW).
0 I,as owner Afton property,w my employm with Willes As their sok compensation.
will do the work and Ne.,,Aete.I,..,intended mo0c.d fmole(Sec.7th/,Busitka
and Profa.iom Cade:The Conuacou's License Law does not apply k an owns,of 3 0 3 - ROUGH Re unleedd lns g!CNI '+tions
pmsany who builds or improves thereon,and who doessuch work himself orthrough his
awn employees,provided that such improvements arc not intended or offered for mi..If. 3O4 — ROUGH ELECTRICAL
however.the building or improvement Is sold within one year or completion.the owner.
builder will have the burden of proving that rte did Act wild or Improve for purpose or 505 — FINAL ELECTRICAL
ale1 508 - FINAL MECHANICAL
❑1.as owner of the property,am exclusively contracting with licensed contractors to
comwct the project(Sec.70".Businms and Professions Code)The Cmtrutori Li.
come Law does not apply to an owner of Ptolemy who Wilda at improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor'.
License Law.
❑I am exemPl under Sec. .B A P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affm under Penalty of perjury rem of live following dalan0onm
I have and will maintain a Certificate of consent to se161nsure for Worker's Comwm
atlnn,u provided for by Section 3700 of the Labor Code,for the performance of the
work for which Nis permit is issued.
I have and will maintain Worker's Compensation Imunna.As required by Section
37110 or do Jaber Cade,for the pedonnance of she work for which this permit is issued.
My Work r..Cyo�npe/Imaion Inauraee artier and Policy number am:
Gamer.3 wYom. Z: Policy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section wed not becomplewd If rhe permh Is forone hunched dollars(SIW)
m kcal
I anify that in the perfnmmnce of the work for which thin permit is issued.1 shall nor
employ any person in any manner an As m become abje,to the Workers'Compensation
Laws of California.Dow
Applicant
NOTICE TO APPLICANT.If,after making this GerllReale of Exemption,you should
become abject to the Wok.,a Com,mothm prevision.of the Labor Code,you most
.J,'Z forthwith comply with such povisinns at this Permit hall W tomos revoked.
.Zi Q CONSTRUCTION LENDING AGENCY
E
vN-' I hereby affirm that there its comtruclum lending agency fnr ft Performance of
rli ► the wok for which this permit is issued(Sec.307,ON,C.)
W Q nder's Name
LA
5 z L<naer'.AacAddo
m•.
U O I stonily Nu I have.ad this applienion and soon that the above information is
In., (r' correct.l g.e to comply with ill city and county oNinarxerand oak Is.relating k
abovengcamtroctiao and her by authorim.oses. las of thiuitymenmr upon d.
O W ahOVe mantkmd Property forinspectiona pkeep ha.
gy (Wc)agree to ave,indemnify n es keep harmless the City of Cupertino against
y toc.itiesjudgmenW costs and A,caponuamit. may in anyway aceto against aid City
UZ in conuguenec of the granting of this permit.
" so RCA DERSTA DS WILL MPLYWITHALLE{ONjINT Issued by:9i4Date
SOURCE LA L/
ZNO� Re-roofs
Signuumof Applicano,conuaet rD' tE
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser fuWre building uccupem amrc or Esodic henNou.makriul
As defined by the Cupertino Municipal Cock.Chapter 9.12,and the Health and Safety
cWe,Section0y.zss3z(a�No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or more wining occupant use equipment ArJcrkes whichIf a roof is installed without first obtaining an inspection,I agree to remove
It wardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Id..
strict7
❑Yoe \usNn
1have rcWthe dc,Sccrosmaterials.33md n5underChapterd ifd.Wilding
no,.&SafehaveaSccdom 3ss05.355J7 vnJ25thilky nJcdf to -wilding
not cu haw a l u my ra hility mury theapnt of theuimmcn echo ri wimu fa a ofOcqup cy./ Signature of Applicant Date
pt as
Owncr or autharircd seem Dee All roof coverings to be Class"B"or better
- CITY OF CUPERTINO
FURNACE/AC
CUPEI�TINO PERMIT APPLICATION FORM
APN# � � / l / � 3r t /' Date:
Building Addres lD 1n 7
Owner's Name / Phone#:
Contracto • Phone: License#:
°� P
73,7-as X65 z G 6
Contact: Phone: Cupertino Business License#:
�` _
Building Permit Info:
Bldg ❑ Electlx Plumb ❑ Mech
J� cripfi n-
G,p� - Ll rOA V- 50 fcm
Residential/�`" Commercial ❑
For Residential Installations:
Attic LJ I` floor ❑ 2nd floor❑
. Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
/0 3/0 . %.T-b
Strapped ❑ On Platform El Bonded ❑ Sq.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
I EPERMITFEE Elec Permit Issuance ELECTRICAL
I MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING