01040083 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22103 STOCKLMEIR CT ATLAS HEATING LA 104 L4 L71 A 3
OWNER'S NAME: AI'PI.ICAI ION SUIT DAII!
F04/17/21710111
PHONE: SANITARYNO, CON]ROL NO,
C-Z ARCM'IECTENGINEIiR: BUILDING PIi MIT INFO
❑ If LDG I].ECI' .UMH FCH
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SNP LICENSED CON TRACTORS DECLARATION Job Description
1 hereby attire.hoar 1 am Iicemed under provisions of Chapter 9(commencing
004_,a�]J will,Semon 7(XX))tt insm( 9..1'the Bminr,,and to.nmdim„Cndo.imdmy Mame
i,in full farce and eftq'I�,�
so B.0 1'ieC"",e cog�y (%LC/ ''"'." 4 (� � PLACE FURNACE" ADD AIR CONDITIONER
Uam t� Commuor FINALED
e LL G n1erlurecrs DECLARATION
Sa°g 1 mWcrmm,d my plans.hall be used as public record,
w�a o Licensed Pmfe<,innal NOV 2 9 2001
e. OWNER BUILDER DECLARATION
1 hereby infirm tire(I u comp,from the Contractor's License Law Iia,hc
F Z a following reason.(Semen 7031.5.puniness and Pmfnsian,Cak:Any city or rowdy
F 0 which cNuoe,.,pemilI......mime,,uher,imvnwce demnli h.nr repair any.wemom
i3°
prior to its issuance,also mquires the applicant beach pencil to life Deigned suit nnenl Bui
that he is licensed pursuant o the plus sums of the Contractions License Law(Chapter 9 q, t.Poor Area Valuation
[en .ming ,,It Section 7(XX)of poliom3 if he 11mmm,,and l'm(msinn.Code)
nr that he is crnnpl thereof it,and We basis for the alleged uncmplion.Any viulmlon
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally
of not tome than live hundred dollar.($5a)), A PN Number Occupancy Type
0I,m owner of the promrty.or coli empl0yn's w ilh wage,as their side compensation. r
will d"the nark,and,he.tont...is=ind rded or offered for sale(sea.7(A4
Basin...and I'mfc,siom,Code:The Cmrtmcta;x 1 iceme law dor,nor al,ply ,,cot Required Inspections
owner of property Who hui46 or improves thereon,and who does such work himself
rc a,hhi,,,wn.mllorec,.pm,;dedbar such impmvcmem,.arenor mundedor 301 — ROUGH PLUMBING
offeml for ml..If.howe,'cr,the building or impmwentem i,old within one year of
completion.the,n,ner-builder will have the burden ofprating that he did not build or 303 — ROUGH MECHANICAL
ntpmvc fur purpose ill lulu.).
p lc mowneraflhc property.ame,cheively conorrom,with licensed enntrac,ono to 304 — ROUGH ELECTRICRL
....Inn,me .,,ice,Ise,:.7044.Im.i"r,.:md Prole,xion,Codc:) Pe Commmill_, 505 — FINAL ELECTRICAI_
Licenm Law des not apply lin an owner of proWity who build,or inmovie,Merrom
and who contracts for such pmjccts with a comrucmgs)licensed pumuant h,The 507 — FINAL PLUMBING
Comm<ror'.Li.cnm Law.
o l am esempt ander Sce. .H&pe mrmi,rem„n 508 — FINAL MECHANICAL_
Owner Dam
WORKER'S COMPENSATION DHCIARArION
I httcby anion ender pemby of perjury one or the Inllowing dcd'.antion,: '
rJ I have and will „Dromic a Certificate of Crown to.elf-insure for Worker's
nnpenwtion. as provided lar by Scetii 37(X) or tlm Luhor Calc, for he
mrourim,ce of rhe work for which this permit is iswed.
❑1 time and will nmimai,,Wodcr',Canpen.atio l Insurance,as required by Section
3701 of the I.aW,Code.for the pedmorm ve nl the work for which this permit i.
ixnucd.My Worker's Cuml/pfl�m�oI on In..mnm carrier
/a�nddd Policy
muurldwe�r�.ano
Carrier: S CArt�NOf li%EMITIION I ROM WORK(RS7 ���
COMPCNSAIION INSIIRANCP ,
I Ihis sconet need tat be.m..pforest if the pemtit i,for one hundred dollars .
A tan of less.)
1 certify that in,be perforno of the work for which this perucL is issued.1 -
,WII not enTlo,any per o r In any manner so,os m hero,'subjeo,u,the Werke”
Compensation laws of Cmilimnia.Date
Applicata
NOTICE TO APPLICAN"1':It.a0cr ,making Ibis Ccnifcam 0 Ic"niption,you sbnuld
benmm subject to the W ko,es Compensation minium,of the lama Code,y......t
Q Q fonbwdh cor,ly if,such pre ,,eons or it!,pem,it,hall be deemed mvoked.
F ^ CONSIRUCIION LENDING AGENCY
a > I hereby alllinn,bo there is a constmction lund'm6 agency Int the performance
of the wod fur whieh,his mnnit ix i...ed(Sce.3dN7.Civ.C.)
rZ 1<ndcis Name
z bender',Add.c„
V Q I.eddy that I have mad this application and statebut the move Information is
Ili F correct.I npwc w vor,dy won.11 city and....nly onlimomc,and,tate Tawe'relating
Q V re building wns,mni...,and hereby tush i,,mnes."tativesof lhi,city e+emer upon
FW be um ve-mentioned property for inspection purposes.
G, (We)aim.to sate,judc,ntily and kap hunnlms,IN Cityof Cupertino against
Vi liabilities,judgmenm,cf
Isu,which may in any way Ocaae u, mi said to
�,1 z City in con yucca of f this pcnnir.
AP1141c I'UNOR WILLCOMPLYWImAJf.NO POINT Issuedb DateOUI 'C /1s,g. ,mo1 nnpnam) sew.— Re- oosHAATERIALS DISCLOSUREWill heappnlardu,occummr.tnce handlehararoa.mamhial Type of Roofodonned by the Ca,' d Cade.Cmgtm 0.12,amt hue I Imllh and Scilly
Code.Section Olin 25532(.)^ ❑No
All roots : all be inspected prior to any roofing material being installed.
Whlbe application more haddmgac.,nam use eshmponid or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
moo do,,,aireontanti"ansm,rimed by bre nay Arca Air Quality ntanagentem
all new materials for inspection. Applicant understands and will comply with
❑Ye. ❑Nn all non-point source regulations.
I nave mad,he onto mmenal,mywremcm,under CWmc,f,95 of be
California Health&Safety Code.Sections 255115.25533 and 25530.1 understand that
ItrheI )dingdolsno,currently Itasca,nnam.fru it ix to,re,moolhilay b,notify the
,capanl or the requimmcnn which nisi he n"I prior,u i...t a of a Ccnilicum of
«`upancy. Signature of Applicant Dale
Ownmo,aatbodaed agent Date All roof coverings to be Class "B"or better
OFFICE