03040137 (2) •.CITY OFCUPERTINO -
BUILDING DIVISION PERMIT %0N IbIV
'VVI SVIDDeEAY ST ATLAS HEATING PERMIT NO03040137
@9"'312 : MAURICE C JR AND JUDITH 155 SAN LAZARO AVE "T"Ed?gre,0/2003
NE: _ (408) 739-0516 SANITARY NO. / -� CONTROL NO.
ARCHITECf7L'NGINEER: BUILDING PERMIT INFO
BLD° ELECT PLUMB MECH
2OC LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby al that lam limn"under provisions of Chapter 9(commencing
with Section 70OR.fDI,Won 3 of the Business and'profcsslons Code.and my license is
I.fu fare and ef(i-L� y6 G 6 RPELACE FURNACE (10000OBTU)
Licen Uc.
9 g1-O Da.enl ?—Comnclar-Pr� .
q ARCHITECTS DECLARATID)
I understood my plan mail W used as public meaAs
6
u Licensed Pro(essionel
50 Oat I am exempt f DECLARATION
TION
Y 1 hereby affirm mall 1. ,Recommitted
econ from the masCContractors :A License Law for the
O O fallowing mama(Sadao RD1.5,Bntnea and ve,du ons Code:Any city orcounty
s$ which requires•permit re enruwe4 alcor,Wprow,de Permit
.r mash any tatement
e3�^ poor u its issuance,also requires the applicant fnmch permit to 0144 a signed statement
I2- < that W is licensed pu numt 1.the provision of the Conp¢Wr'.Umnse Law(Chapmr9 Sq.Ft. Floor Area $2� tion
Y€O (commencing with Section 7000)of Division 3 often Business and Profusion Com)or
Nal he is exempt therefrom and the basis for did,alleged!exemption.Any vial Wan of
Section 7031.5 by arty applicant for h permit subjects the applicant to a civil penalty of 3 0 Occupancy Type
not mom Nan Rw hundred dollar($300).
❑I,as owner arms property.or my employes,with while u their role campenati0n.
will do the work,md dt atmcture is notimemied oroRered fm aak(Sec.7044.Business — XUUGH
and Prole.ions Code:The Cadavers Lice=law dents rot apply Wan owner of 303 - ROUGH HAN I AL ns
property who but Ids or improves discmon,emission does such work himsef or through his
own employee.provided Net each improwmentime notimended oroRered for We.IL 304 — ROUGH ELECTRICAL
bawever,the building or lmprowment is mid willdn one Kar ofeamphtiou.dW owrea-
Wllaerwillhawtimburdenofprovingthat hedid no,Wild mlmproverorpurposeof 505 - FINAL ELECTRICAL
save.). 507 - FINAL PLUMBING
❑1,a Owner of the pmpmy,am exclusively contracting with licensed conuacmra W 508 - FINAL MECHANICAL
construct the project(Sec.7044.Business and Profession Code:)7Th Commenor's Li-
cense law does not apply W an owner of properly who Wilds or improve dmmon,and _
who comm cta fa such projects with a contractor(s)licensed pursuant W the Compactor's
License Law.
❑Ism exempt undo See. .B&PCTs thb mean
°w WORKER'S COMPENSATION DECLARATION E
teacher
entry
ty of
desclaramonse
Ihve and wll11mainWnaCWRmma Consepmbf�lown,far Worked Camper- "I E '�
anon,a provided fm by Secdon 3700 of the Labor Code.Ire the perfommu m of W
wart for which this permit is hued.
I haw and will maintain Workers Compensation lumen uses,as required by Section
3700 of use labor Cade.fon the performsom of the mass for which this permit u Issued.
My WeryCam later,
�lwn,.nce carrier and Policy number am:
Gnier.(.ffl l///uytH,sr�"Policy SktiZ ' 351
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thusectiat reed ant W complexed If the path is faore hundred dalan($100)
or Wu)
1 certify that in the performance of the work for which this permit is issued.I"I not
employ any penes.many nuumv.as W became subject is the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this CeniRmte of Exemption,you should
became subject W the Worker's Compensation provisions of the Labor Code.you mus,
.'O forthwith comply with such provision or this permit shall bo rimmed revoked.
z� CONSTRUCTION LENDING AGENCY
[.r I homey affirm that Nem is a coruwctimn lending agency for the performance of
a> the wort fa which this permit is trued(Sec.3097.Civ.C.)
W Q Lender:Nam.
Z Lender':Add.
() I cenify that 1 have mad this application and mie that use abow information It
!L F correct,I agree W comply with all city and county on insdms and sum laws relating W
CU Wilding construction,and hereby authodm representatives of Nis city W env upon Ow
W ahove-mendonW pmpeny for Inspection purposes
(We)agree W saw.Indemnify and kap barrel.the City of Cupertino against
En liabilities,judgments.costs and expenses which may In my why seems against aid City
(J in consequmm of the granting of this permit.
z APPLICANT UNDERSTAND$AND�j...LLL COMPLY WITH ALL N POINT Issued by: Date
SOURCE REGULATIONS. �f � ! S
f� fiD Re-roofs
Signature of Applicant/Con ontOr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will don applicant or future building Oceupmumre or handle haeardaus mamdai
as darned by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Secdan 25532(a)?
Yea All roofs shall be inspected prior to any roofing material being installed.
❑ ❑nes
LLWill the applicant or prime building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
haardnus err conuminmu as deRned by One Bay Are Air Quality Management all new materials for inspection.
DiuricO
❑res bwlr�
I have mad the hassolum materials requirements underChapter 6.95 of dm Califor.
nia Health&SalsyCade,Sections 25505,25533 and 25534.1 understand that lfthc Wilding
does cot eurrtmly have a tanant.used it u my raepnrWbilily to sadly the aces, t of Ne
require.. w]0t�� elpnarWlssonceOfaCcrdOnuofOce Signature of Applicant Date
l�� ,
owner pranmenma.e D All roof coverings to be Class"B"or better
CITY OF CUPERTINO 7
FURNACE/AC
' CUPEkTINO PERMIT APPLICATION FORM
APN# 3 G 9 - 3 `_ nD 2 / Date:
Building Address: Zo 3 6 7 cX 0 g. �
Owner's Name: Je v��ir Phone#:
` kPI cu ✓u w O 0 2S 7-!S V9
Contractor: Phone: License#:
a4xa,cL., 735
Contact: Phone: sem_ Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
o o L) B 7-u
Residential �Pr— Commercial ❑
For Roldential InU llations:
Attic LJ Is` floor 2"d 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 ofProject:3� Type of Construction: Occupanc group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
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
EPERMTTFEE Elec Permit Issuance ELECTRICAL
!" MPERMTTFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING