01070055 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS PERMIT NO.
1198 RUPPELL PL ATLAS HEATING 01070055
AME APPLICATION 5UB DATE
OVW MASOUD 155 SAN LAZARO AVE 07/13/2001
1
PHONE: (408) 739-0516 SANITARY NO. CONTROL NO.
a-Z ARCH]I-ECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB SUCH
LICENSED CONITKACTOR'S DECLARATION Job Description
I hereby a mot licensed under previsions of Chapter 9(commencing
"m that I list � a.rVy license
ith Sonim,70ST,,,D,,,,L,,.r.(,he B rb,,.W!V��fcml REPLACE FURNACE, ADD A/C.
in full force and eff
ca Limnx�p cr,-Zo Ilu
X is act Dale Common., nn!tl' ymn
se ARCH[TECT'S DECLARATION
I modrommil my ]are hill be used as public record,
FINALED
R -2 Lionosid Professional
a.
,or OWNER BUILDER DECLARATION
ec'e.
I hereby affirm that I am exempt from the Contractors License Law for the JUL 2 6 2001
I-Za- fialhosiving mention.section 703 I.S.Business and Ponfiossions Cost Any cry or county $5000
��_9 which requires a permit to constract,alter,improve,demolish.or repair any shousturs,
la
ce 5: prior to its issuance,also requires the applicant for such pennit cc rile a signed statement
four W i,licensed pavAmr,of,he Committal.,License Law(Chapter 9 UILUING Valumion
n(command,with Section 7")of Dwimad 3 of the Business innif Pont...Cods) v
a, has he is exempt flubefrod,and the Inui,further liflilad inmarpd...Any violation
-Of Section 7031.5 by any applicant far.permit object, he a,,I.bcni to o civil ro.1,
.of Out mammal rose hundred dollars(115SP. 3 0 JAPN k1gil PLUMBIN Occupancy Type
0 1,as owner of the f®refeet,or my employers with wages ax their sale con,sm,ation, 303 - ROUGH MECHANIIAL
will do the work,and the xmicturc is not intended or offered for sale(Sec,7�,
Business and Pme,,irm,Code The Comme,cC,License Law due,to,apply 1.on 304 - ROUGH ELfi5fqT6R2- (rAlkctions
owner of propsibny Who builds or improves thereon.and who does such work himself 501 - FINAL ELECTRICAL ENERGY
.1 through his own employees,provided that such improvements sup not arproled or
Offered for sale.It,himaxer:the building or improvement is sold within one year of 502 - FINAL PLUMBING ENERGY
completion the cow.ar-bedd.,will 1,a,b the burden of pr....I bar he did not Wild or
fir"mrsmi,cif 503 - FINAL MECHANICAL ENERGY
OF,to 505 - FINALT ELECTRICAL*
0 1,as owner of the property.am exclusively contracting with licensed contract
courSomad the prumect(Sec.7044.Business anti Professions Coo:)The Ctionon,ar's 507 - FINAL PLUMBING
License Law does not apply to an owner of pon,inny who Wilds or improves thimmon.
..ad who ecurrom.far such projects limmom,10 licensed pursuant 1. he 508 - FINAL MECHANICAL
Commators License Law.
El I mr,excrop,under Si B&P C for flo,reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affiron under Penalty of Perjury one of file following undulations
I have and�Hl maintain a Certificate of Consent to seffinspor for Workers
Compensation. it, owickd for by Scott.., 3700 of he Lafor Code. for he
peromat Of the work for which this permit is xOmd.
[I I hr�c and will maintain Worker*s Com,easation Insurance,as required by Section
3700 of the L.NarCode,to,the rimmunce if the work far which this ,.it is
iwiund.M� W arx Insurance carrier and Policy number am
C
,CCR I C NTION 01;EX FROM WORKERS
COMPENSATION INSURANCE -------
Thi,section need no,he sion,leind if the Permit is for ru,hundred dollars
($100)or le"')
shall not employ any Person in any manner so us to becomm'subject to the W,ollum;
Clooprioad,an I-,. r Ca I i�uma D.im
NO]ICE TO APPLICANM If,after making this Cerifficam of Exemption.you should
z bi�xmmsubjecr to the Worker's Compensation previsions of the Latior Cul you must
fomdowiddi loomly lidl ILAF lem,minso,dii, crout hill be decimal moma,d
z 2
(Z) CONSTRUCTION LENDING AGENCY
I hereby offirm that here is a constimcium lending agency for the performance
0 in Or,hin
a, Illich this'limit is o.rd gre.3097,Ci,C.,
Under*,Name
z Lencle,',Address
oc,rmcl.
to Wilding commarrion.and hereby authorize representatives of this city to enter u,oa
W herisevermemirnon!pre,rin,ftirm,neco I an purposes
A� 0`10a,ma luici,c.ind,ornir,and I.oio,hit lost the City of Cumnim.a,c.O,L
IZ) owl,end e.speasrs which may,in any way recon,agion,t%rid
z City in consequence. I a .a . this promit.,
APPLVIACTUNDERSEAND AN)WIL INT
CA Ided by: ---.i Date
sow C, G I Iss
Si,nato—reof in licatuttContriliplu'7, Dale Re-roofs
"Co
AZARVOUS IA RIALSDISCLOSURE
Wl�l"he appl!art a,tuttim bui ing mountain ston,or handle brundous internal Type of Roof
I ff
�d'�11 letherp"! 4mmurnpall
as der,
Cush,
All roofs.shall be inspected prionto any.roofing material being installed.
Will he il,hcant or hinum buildn,ot,stmetran,a equipment or devioc,which If a roof is installed without first obtaining an inspection� I agree'to remove
con,hu,iiandcos muccontaminarts as derined!by the Bay Area Air QualloyManagement
all new materials for inspection. Applicant understands and will comply with
Ely,, ON.
all non-point source regulations.
I exibill hirvotlicrimi,materials requirements,under Chapter 6.95 of the
calihori�`H!illffr&' fciy We.Sections 25505.25533 and 25534,1 understand that
'-if,m1Widm,dmc, ten orly have a renain,that it is my resp ., .
0 1 ty to n I t a
coup (f be c,.i em is which me,,be oved Prior to ,rance it a C ,, care or
or 6 ) Signature of Applicant Date
Inh ImA
i.. an Data All roof coverings to be Class "B" or better
OFFICE