03080091 a CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT WOADDRESS: N�TRACTnR INFORMATIQN
BUILDING ATLAS HEATING PERMIT NO
I 03080091
OWNER'S NAME: 155 SAN LAZARO AVE YERMITI.SUEDATE
HELEN SEVERNS
NE: (408) 739-0516 SANITARY NO. CONTROL NO,
ARCHITEC-UENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Oo LICENSED CONTRACrOR'S DECLARATION CI O O O
a+p I hereby affirm mat I.m I d endo rev.. a nfcha 9(comms cine lob Description
tZw wish Scmion 70018 of Diviaion3of the Oosin rd Poore ndmyli-n if if
+tea m immma s eh p 'Q-REPLACE PKG UNIT ON ROW-1 W-1
;Mz Li cenx Class I�
+�qDam cnwctor
ARCHITECTS DECLARATION
Es IundcmmnJ my plain shellbeuud es public rccnrJS SEP 2 4 2003
31<
u.tiCl Licensed ParNssional
OWNER-BUILDER DECLARATION
<F 1 hereby affirm that I am exempt from the Contractor's License Law for tM 13UILDING
00 following reason.(Section 7031.5,Business and Professions Code:Any city m county
$ which requires a permit to construct,alter,improve,deamish,or repair any structure
prior ha am issuance,also requires the applicant for such Permit o rile a signed summent
cx
< that he is licensed Commit in the provisimu of the Connector's License law(Chapter Y Sq. Ft.Floor Area Valua[lon
21-0 (cat he I,aeonwith Senforanon d the
Derision 3 of the Buair,csa and st.Any
Cone)or
— Net he is eeempt thcrefmm sod the beau for the alleged eump0on.Any violation of 35602039 . 00
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of AISN Number Occupancy Type
net mom man five,hundred delta.(ssDo).
I,as owner of the property,or my employees with wages a their solo compensation.
will do Ne work,and the structure is not intended or offered for sale 7004,Businesa ROU"H—
and Professions Code:The Conuacmri License Law dins not apply to an owner of 303 - ROUGH M CHANT A[Ons
property who builds or improves thereon,end who doesauch work himself or through his
Own employcas,provided that such improvements ere not intended or offered for ale.If. 304 — ROUGH ELECTRICAL
however,me building or improvement is sold within mm year of completion,the owner.
but mer will have the burden of proving Nat he did not Wild or improve for puryox of 501 - FINAL ELECTRICAL ENERGY
5d1e.). 502 - FINAL PLUMBING ENERGY
❑1,as owner of the property,em exclusively convecting with licensed contractors to
construct he project(Sea.7M,Business and Professions Code:)The Convector's Li. 503 — FINAL MECHANICAL ENERGY
cense law does not apply to an owner of property who Wilds or improves Hereon,and, 505 — 'FINAL ELECTRICAL
who contracts for such projects with o cou
ntraetorp)licensed purvano du Contracting
LiceaaeLaw. 507 - FINAL PLUMBING
❑I am exempt under See. ,B&PC for this moan 508 - FINAL MECHANICAL
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury arc of Ne fallowing declarations: -
I have and will maintain a Certificate of Conseml to self.insore for Worleei s Compere
cation,as provided for by Section 37M of am Labor Cade,for the performance of the
weak for which this permit is issued.
have and will maintain Workers Compensation Insurance,tar mquired by Section
7 ofthe Labor-Cook.for the parformanceof firework forwhtch Nis permit is issued.
My Work Cempen/sgY/�µn Ins5u�n�ru�o�aart�ie�r end Policy nurqLhpar ewre:
Carrier. '' '�aa./-tai=Q�cliey Nl`\ zsl 92- 70•
CERTIFICATE OF EXEMPTION FROM W ORKERS'
COMPENSATION INSURANCE
(This Section need not he completed if the Permit is for one hundred dollen(Sip+)
car IcssJ
1 certify mat to the performance of the weak for which His permit is issued.I shall not
employ any Person in any mannersn as In became subject o the Workeri Cempansmlon
Law,of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become Subject m the Worker's CompensallOn provisions of the labor Code,you must
.J Z forthwith comply with such provisions or this permit Shall Im deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
[—i rN• I hereby affirm that Here is a conswctina lending agency for the perfmmancc or
fLv r�-r die works for which His permit is aimed(Sec.3W7,Civ.C.)
{g1 Lender's Name
z "er's Address
U O 1 cenify Hat I have read Nis application and ruts that the about information is
CL. P: comm.l agree to comply with all city and county on insnces and sum laws relating to
0O building construction,and hereby authorsu representatives of dill city to enter upon lire
G ahow-mantioncd property for inspection Purpoua
(~
(Wo)agree to save,indcmni fy and keep harmless the City or Cupertino against
N l'abilitles,judgmc costs and tsps bleb meyi any way seems against seta City rte/
C)7 in conuyucncc cgrantin t ' it,
•7 APPLI AN D D A ALL NP INT Issued by: Date
SOURC
Re-roofs
. HAZARDOUS
Sisnemrc or APPliDem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Juapplicomter future buildinge,Chanlnmrcor and the
Health and
as defined by the Cupeninn Municipal Code.Chapter 9.12,and the Health end Safety
Code.Scales 2533$a)?
r-1 Yes All roofs shall be inspected prior to any roofing material being installed.
[ —
Will the applicant of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7Disvict?
il hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes1 have maul Ih4 haaarHms mamrials mquiacmenu uder Chapter 6.95 of the Caldia.
x Heslth&Safety Cade,Sccumu 25505.25533 and 25534.1 undcrsund Nal ifthc buildingta , yquimmcn ¢hints c du oissuanc aCcruRcauofOccu r. Signature of Applicant Date
3
OwnAll roof coverings to be Class "B" or better
t' CITY OF CUPERTINO D 3
FURNACE/AC
crry Of
CUPERTINO PERMIT APPLICATION FORM
APN# �Z � Date:
/-CJ3
Building Address:: .
Owner's Name: 0 Phone#:
2S 7—230
Contrac(��tgt: � Cwt Phonk License#:4or 6.S 2 6ii �o
`M Z39—OS /e
Contact: Phone: 0 Sl& Cupertino smess License#:
Building Permit'Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
a e 07L
Residential Comrhercial ❑
For Re idential In fellation:
Attic LJ ls`floor LJ 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:` 890 sP Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
AppliAle Fee ID Fee Description Fee Group
BENERGY Energv 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
EPERMPI'FEE Elec Permit Issuance ELECTRICAL
MPERMPI'FEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING