03100130 ( •CITYOFCUPERTINO ,. - rx z ,tf ys�:
BUILDING DIVISION PERMIT SCO p RACTO-' R INFpRMATIO,N
BDILDINGADDRESS: ATLAS HEATING PERMIT N0.03100130
OWNER'S NAME: 15S SAN LAZARO AVE PERMITLSUEDATE
FELS CHARLES W AND MARY J TZUS 2003
NE: (408) 739-0516 SANITARY NO. CONTROL NO.
ARCHITSCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100
f LICENSEDCONTRACTORS DECLARATION
I hereby afrirm that I am licensed underprovisions of Chapter 9(commencing Job Descriptiontion
with$.Woo]G))af Divsion SofNC Business andpofcssiva
Code.and my license is
± h mmBfmc,.nd feaf2_o 2(o b.7 REPLACE FURNACE /
o 11Z License Class Lic.N _
p,
DOW Cuntrat /
qq ARCHITECT-S DEC RATION
I W I undersand my PI.n..h.11 M used as public rcc.m.
`o Licensed Professional �j
OWNER-BUILDER DECLARATION (/7
<I I botchy aRnn that I am exempt from the Contractors License Law for the
Mfollowing mom n.(Section 7031.5,Business and Professions Code:Any city of county
which requires a permit 10 Construct,alcor,improve,demolish,nr repair any structure 81677
-iy prior to is imumco,also requires the applicant fur such permit to file a signed swervint
ESG that he is licensed pursuant m o the pmvisioof the Contractor's licence Law(Chapter 9 Sq. Ft. Floor Area Valuation
11- (commencing with Section](IBO)ofD,virion 3 of the Businev and Pra(essinix Code)ur
,5S that he is exempt theafrom and the bussu for the alleged exemption.Any violadan of 3591402S . 00
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occu anC Type
- not more than rive hundred dollars(S500). ' - - - P Y YP ---- -
❑1,as owner of the property,or my employees with wages AS their sale compensation,
will do the work,and the sWmYR is not Intended or offered for%al.(Sec.7W.Binia t Required Inspections
And Pmfeaions (•i Code:The Commuters License Law does not apply to an owner of q p
property who builds or Improves thereon,and whodoessuch work himmifor through his
own employees,provided that such improvements am not intended or offered(or sale,If.
however,the building or improvement Is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or impmve for putTeme or
sale.).
❑h as owner or the property,am exclusively contacting with licensed eanoactor,us - -
conswct the project(Sec.7044,Business and Professions Code:)The Chronicler'.Li.
come law does not apply m an owner of property who Wilds or improv theaun,and,
who contracts for such projects with a contacmr(s)licensed pursuant o the Contractor,
Licence Law.
I am exempt under See- ,B&PC for this..on
Owner Data
WORKER'S COMPENSATION DECORATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will mainain a Coniricam of Consent m self-inwhe for Wam,'xComfort.
7c,
on,as provided for by Section 37M of the Labor Code,for the pe rfommma of the
h far which this permit is issued.
I ban and will maintain Workers Compensation Insurance,as mquired by Section
W of the labor Code.for the performance of he work for which this permit is issued.
Workw',,���Cno�m� ;aew.on/inpm�n.ca/R�id Policy number art:
nenz UA- WY✓saw YYypolicy No.:3-7 A Q Z�
CERTIFICATE OF MEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thusectitm need notWcomplered iDbcramait lsimonchundreddolleani l)
or Ica,.)
1 ccdify Not in tla peffiomme.of the work for which this permit is limed.I shall net
employ any person in any manner so a to become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL eller making this C.rti5care of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code.you most
�z forthwith comply with such provisionsnthis permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby 4alrm that there i,a construction lending agency for the Performance of
Y, > the work for which this permit is ivucd(Sec.3097.Civ,C.)
4 Q Lenders Nam.
3. z Lcnd,ex Address
J Q 1 certify that I have mad this application and state that the above information is '
y correct.l agree to comply wit all city and county ordinances and mare laws relating to
ALJ building comoction,and hereby authorim mpresemstwe ufthis city to enter upon the
1 abevcmentiuned property for inspection purposes.
(We)agree m cove,indemnify and kap tuneless the City Of CUP(mint)agaimt
to Iiabllidex,judgments,costs and expenses which may In any way aceae against aid City
J in croso,mince of the panting of this Permit.
APPLICANT UNDERSTAND NO WIL COMPLY WITH ALL N N-POINT Issued by: Dat
SOURC GUL�ATI� S
— �p on tar �d ID�7 Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the rep,liew,or future building nett ani.tore w handle hareda,material
a defn.d by the Cupertino Municipal,Code.Chapter 9.12.and the Health and Safety
Coda,Scnion 7553$a)?
❑Yea All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mare building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit havamnus air conamiaants a derincd by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Ya �No ^ �s .
I have mad the luraNnusmamrialstequimmcnts underCh ler 6.95 of the Calder.
nix Health&Safety Code,Seem=25505.25533 and 75534.1 undcaand that ifthe Wilding
dux not curtenily u nsm,th.nt u y respomt hit ity m nod l'y the Ott Pant of the
rcyuimmentsw ' 9bem d �wnaearp�enife .110cey cs Signature of Applicant Date
g, 1,11 All roof coverings to be Class „B" or better
Owner Lar authorirnda col Due
aot�v
CITYOF CUPERTINO o
FURNACE/AC `' l3
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: / 3 711 Cr—�
Owner's Name: Phone#:
Cw - � -S 3 0
Cont r or: Phone: License#:
� �✓� -23 2 -0 5 17/Z -S 6
Contact:/ Phone Cupertino $users License#:
(Z"
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:, �O K
C—/0
Residential Commercial ❑
For Re idential Installations:
Attic M ls` floor ❑ 2"d floor❑
Adhere to min set back re uirement❑
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:
A 7 7 - 6b
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
cable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
if 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
! EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance' MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
O
CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACT RUIIRFORMATµIAN"i.-'" WN WATF
BUILDING ADDRESS: ATLAS HEATING PERMIT NO.03100130
0-4-71 TA7PqTAf-]Rr,2
OWNER'S NAME: PERhm ISSUEDATE
NF SANITARY OLNO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
;30o LICENSED CONTRACTOR'S DECLARATION Job Descri tion
affirm i I hereby arm Nal I em licensed under PO WWmmi of LTapler 9(Cammcnein{ P
_< with Section 7OD)of Division 3 of di,Busnea end POdaaluns Code,and my he...is
'< nfull eClaim Affect. REPLACE FURNACE
me D to Glace LLe.g
�� DoteRECSDECr II
ARCHCTS DECLARATION ((��
I unticaanJ my Plain shall be esti As Puhlle records
3w0 Liccnatl Professional
OWNER-BUILDER DECLARATION
I hereby axo amen the 1am 1. .Bumph from the Contrns Co License Lew for the
pO followwhichingmassa. emilt R)k1.5.Bustnesand
ove, edonsd.Or
ndy it orcounty
$ which rtquira a permit W cMLNCI,alar,improve,demo)W,nr repair any swctum
o
prior W its issuam'e,slw require use applicant forsuch permit m rite a signed smilemcen Valuat On
that he is licensed pumuam to the provisions or the Contractor's Uansc LAW(Chapter 9 Sq. Ft.Floor Area
p�a (commencing with Section 7")of Division 3 of the Business and Professions Code)or
�.. that he is exempt therefrom and the basis for the alleged exemption.Any vtolattoa of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 3 MIN4`NMgro 0 Occupancy Type
not more than Eve hundred dollen($500).
❑I.u owner ofthc pnpeny,or my employers with wage as their into compensadun,
will do the,work,and Ne structure is not intended or offered for We(Sec.101/.Business Required Inspections
and Professions Code:The Conuacars Liana law don set apply W an e Owner of q P
property who Wildsorimprases drcrecn,andwho doeasueh wmkhtmself or Wough his
awn employes,provided Na such impmwmenu an,not intended ordained("rale.if.
bawave,Ne building or tmprowthom is sold within mte year of ounpindmi.the owner-
builder will be.the burden of proving the he did Out build m improve for purpose of
ale.).
❑1.as owner of dm property,am exclusively contracting with licensed contractors to
construct tite Project(Sec.7004,Business and profusions Code:)The Canlnclura Lt"
cense law docs not apply to an owner of property who builds or improves Nemon.and
who convects for such projects wird a conuaclar(s)licensed person In the Contra,loes
License law.
❑I am exempt under Sac .B h P C for shim name
1037."00
wner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 haw and will maintain a Certificate of Cement W selfdnsure for Worker,Compan
ian.u provided for by Salton 3700 of the V bee Code,for Ise met....of the
rk for which this permit is issued.
I haw and will maintain Workoe3 Compensadaa Insurance,a required by Secdon
ofthe labor Code.for the Performance ofNe work for which this peon h issued.
y Workers Compensation Insurance carrier and Policy number are:
rtier. Polity NO.:
'CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This rxdan need nor hecomplered film permit is farmte hundreddollan(SIM)
or leu)
I centfy that In the performance Or the work for which this permit u issued,1 shell not
employ any porion in any manner an a W become subject to the Workers Confirmation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Con ricate of Emm,dtm.you should
become subject W the Worker's ComPensuton provisions of On Lahr Code,you must
OfoMwith comply with such Provisions or this pmmil shall be darned mmked.
z .^y., CONSTRUCTION LENDING AGENCY
(-t I bereby elrtrrn than them is a cmutrnchan Lending agency for the Performance of
rG > the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender',Name
] z Lender'anddraa _
V Q 1 ardfy,that I haw mad this application and state that the above Information is
D.U correct.I agree to comply with all city and county ordinances and smile lava mining to
C) building construction,and hereby authors representatives afthis city to enter upon thc
Gil asove-mendoned property for ieSpeetian Purpedea
(We)as=W sew,indemnify and kep harmless the City of Cupertino against
in liabilities.judgmems.costs anti expwcs which may In any my sous against said City
U inconsequence of Oc Smuting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON"POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of ApPlicantDate HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of faumi,alCooccupant no=orAnd Health And Safety Am defined by dee Cupertino MuninPal Code.Chapter 9.12,and the Health anis Sa(ey
Code.Sedan 25532(a)? All roofs shall be inspected prior to an roofing material being Installed.
❑Ye 0 N P P Y g 8
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haardnue sir conmiminants as d.1mcd by the Bay Ama Air Qualimy Management all new materials for inspection.
District?
❑Yes [IN.
1 have mad the bevarduus materialaequirements under Chapter6.95 Of do califor"
nix Neu"&Sa(ety Code,Sections 25505.25533 and 25534.1 understand them lithe Wilding
does not currently have•leans that it u my resimandhil4y to notify the=Want of the
mquircmms which mum he met poor W issuance of a Cortifoam of Occupancy. Signature of Applicant Date
Owner or authorized agent Data All roof coverings to be Class rB" or better