03070009 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ,;
auILDINGADDRESS: ATLAS HEATING _ PERMIT No.03070009
• OWNER'S NAME: 155 SAN LAZARO AVE PERMIT ISSUEDATE
,7014N T4TJLqT4F.R _=101 /9
NE: . (408) 739-0516 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION
U- 1 hcmby efBrm that I am licensed under provisions or Chapter 9(commencing Job DOSCflpt100
with Section]lNll in Division Sof NC Ruai ss a��}dfpr fcyyio dmy liccnx is
U1 7 7
r,3 inrmlmrcetnearr�m 20 a REPLACE FURNACE
j�2 Llttnx a g
Dau T ARCH CTS DECLARATIO (a
I understand my plansahill W used a public records AUG 2 6 2003
w
a
k Licensed Pmfcuinnel '
OWNLOER DECLARATION
i 1 thereby affirm thus I amm exempt from tW Cnmmmoh License Law for the
BUILDING
i
00 following moon.(Section 7131.5,Business and Professions Code:Any city or county V V7
$ which¢quips a Permit to Construct,altar,improve,demolish,or motif any structure
poor to its issuance,also require be applicant for such Mrmiuo file a signed staument
gta<
the,heI,licensed Pununnuntbeprovisions orthe Contractor'sLieenuLaw(Chapter 9 Sq. FL Floor Area Valuation
pN$ (commencing with Section 7")of Division S of the Business and Profnsinns Codc)or
y .. Nat he is exempt therefrom and be buss for Ne alleged Confif ien.Any violation of 31623084 . 00
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than rive hundred dollar,($50B).
❑I,as owner of the property,or my employee with wages As their sole compensation, pp
will do the work and the swcmre is not intended or offered for sale(Sec.JOM14,Business — @' Ct1005
and Pheressiou Code:The Contractors Licervu law dose not apply to an owner of 3 0 3 - ROUGH M CHAN CAL
,moan who builds or improves thereon,and who doeauch work himself orthrough his
own employees,provided that such improvements vent intended oroRezed for Ads,If. 304 — ROUGH ELECTRICAL
however,the building or improvement is old within one year of completion,Nc owner
builder will haus the burden of proving that he did not Wild of improve for pmlwse of 505 - FINAL ELECTRICAL
.to I
❑1,as owner of the property,am exclusively contracting with licensed convectors to 507 - FINAL PLUMBING
construct the project(Sec.]044,Business and Professions Code:)Do Contractor's Li. 508 — FINAL MECHANICAL
cense law dose not apply to an ower of progeny who Wilds or improves Ihemon,and
who contracts for such pmjecm with a contractor(s)licensed punuouo the Contneto8
License Law.
rl I am Coup,under S.C. .B&P C fu this recon
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of the following declanllom:
1 have and will maintain a Certificate of Consent self-insum for Worker,Cumpem
Aaron,as provided for by Section 571)0 of the labor Cade,for the peramonec of the
wark for which Nis permit is issued.
I have and will maintain Worker's Compensation Insurance,As required by Section
7!111 of NC labor Code.fu on,pednrmance of the work for which this permit is issued.
My Work Camoen trop Insurance ea^rtiu end Policy num
Certicrl.(�C�s��a�//LFJiK.R+Ppllcy No.. _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
( isseetion recdnothecumoleud ifthe permit Isforone hundreddollars(Sine)
or I.A.)
I certify Nat in the performance of the work for which this permit is issued,11112111 not
employ any person in any manner an o to become subject to be Workcrs Campemation
Law,of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccniricate of Exemption,you should _
become subject to the Worker's Compensation provisions of the Labor Coda,you must
.JO forthwith comply with such provisions or Nu
is permit he deemed revoked.
Z M CONSTRUCTION LENDING AGENCY
[-� 1hereby affirm NU Nem is aronnrvctinn leading for Ne perfmman.of
W' Ne work for which this permit At issued(See.7097.ON.C.)
WA I<ndcr's Name
z LcnJcr's Address
V Q I certify that 1 have read this application and sou that due above information is
cortect.1 agree m comply with all city and county ordinances and sou laws relating to
V building consumreuti
etion,and hereby authorize mpenves of this city to enter upon the �-
to abovo-mentioned Progeny for inspection pugmxa
y (We)agree m eve,indemnify and keep harmless Ne City of Cupertino agaiut
D, liabilities,judgments,costs and expansion;which may in any way ucmc against aid City
U z inconsequence of Nc gr, g a!Nis u.
'—' APPLICANT UNDE NLLS OMPLY THA NON�POINT Issued by: Date
SOURCE REG�B���,� 'I 1�0
Re-roofs
Signatureof
HAZARDOUS
AppliceO Delc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or Tatum building eat nom n
or handle h, rduuaeafest
d
u defined by NCu
e Cupertino Municipal Code..Chapter 9.11,otl the Health and Safety
Ini.
de,Section 25552(a)7 �� All roofs shall be inspected prior to any roofing material being installed.
❑re
Will the applicant of future building acupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
It bouardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection. I
strict?❑Yes1 have msd Ne Wo dous matc,ols mquifcmnts under Cher=6.95 of the Califon Health&Safety Conk,Sections 25585.15555 and 255]4.1 undscnmM thin irlW building,
,oat memc,mh me•Lena Na myru, yy'lohl'wnotifyte aeupu n(uiremcno m t issuance iCcnifR4taofOccup
Si gnature of Applicant Date
Owner or authorized agent etc
' All roof coverings to be Class "B" or better
1
a
CITY OF CUPERTINO
FURNACE/AC e, -3 `'
CUPEkTINO PERMIT APPLICATION FORM
APN # � _ ✓ G Date: 7//
Building Address:
Owner's Name: �- ¢w v'/' one
ctor: Phone: License#:
ContM
739 osIL g6S2-
Contact:ao-z_� Phone: Cupertino Business License #:
Building Permit Info: 7
Bldg ❑ Elect Plumb Mech
Jo Desc 'ption:
o-c e 000 IM . 04a Q C 37-C,
Residential Commercial ❑
For Residential In tallations: I�
Attic ❑ 1" floor LJ 2"d floor❑ r
• Adhere to min set back re uiremen u-4 a aA",- ze-P.
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: ,x7 Type of Construction: Occupancy group:
6. 71,3
Strapped LJ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location XA/CRe lacement a-c-R--
Qty. if
Apoti.,able Fee ID Fee Description Fee Group
Isv 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
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 BU ING