03100049 (2) CITY OF CUPF,RTINO '" * °"' i
BUILDING,DIVISION PERMIT CONTRACTOR IIVPORMATION
BUILDING ADDRESS' ATLAS HEATING > PERMIT NO 03100049
WNF:R'S NAME: 155 SAN LAZARO AVE PERMIT 13SUEDATE
NE' (408) 739-0516 SANITARY NO. CONTROL NO.
ARCf11TECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MGCH
loo LICENSED CONTRACTOR'S DECLARATION (•� O O O
as F 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
'ice with section 7(Nxp (Division 3Of the Business and P tq i1 d�a licence is
ica? in full force and Offgt. —, Tb RNACE ��,ya
License Cl uss ` Lic M FON
;, n Date�/�CO0
ti i < ON
1 understand my plans shat he..it as puuie ncrind,
aa0
MAR 1 9 2004
gip~ LiccnscJ Professional
S OWNER-BUILDER DECLARATION �r�,
j a S I herchy affirm that I am exempt from the Contractor
License Law for the r��l i��n ®�rf�w
p O following reason.(Section 703 1.5,Business and Professions Code:Any city nr county aYfl UJ 1. YNllf�/w!
1 m E which requires a permit to construct,alar,,improve,demolish,or repair any structure
pncruids issuance,also requires the applicant for such permitlo Glc.signed estimator
< that he is licensed pursuant it)the provisions Of the Contractor's Licion,Law(Chapter 9 Sq. Ft. Floor Area Valuation
�FG (commencing with Section 7000)of Division 3 of the B usiness and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 3 16 2 9025 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ApN Number Occupancy
not more than five hundred dollars(S500). P Y Type
❑1,as owner of the prefacing,or my employees with wages as their sole compensation,
will do the work.and Be summure is not intended or offered for salt gee.7846,Business —
and Professions Code:The Cnnactor's License Law does not apply to an owner of 303 — ROUGH M CHANI AL ns
Property who builds or improves thereon,and who does such work himself or Brough his
own employees,provided that such improvemrms are not intended or offered for satc.If. 304 — ROUGH ELECTRICAL
however,the Wildi ag or improvement is sold within one year of completion,the owner-
builderwill have the burden ofpra,mgtrial he did not Ind Rdorimprove for purpose of 505 — FINAL ELECTRICAL
scief.
❑ 1,ax owner of Be property,am exclusively contracting with licensed convectors to 507 — FINAL PLUMBING
consumer the project(sea.7066.Business and Professions Code:)The Contractors U. 508 — FINAL MECHANICAL
cone Taw docs not apply to an owoct of pmpcny who build.,or improves hereon,and
who contracts for such projects with a comrachi licensed pursuant o the Contractor's
License Law.
❑1 am exempt under Sec, B&P C for this reason
Date
II WORKER'S COMPENSATION DECLARATION
`I17M
/ I hereby aRirm under penalty of perjury one of the fallowing declarations:
have and will maintain a Cenificac of Consent to self-insure for Worker'xCompan-
n,as provided for by See ion 3700 of Ne labor Code,for the Nolmmance of the
k for which Bis Permit is issued.
have and will maintain Worker's Compensation Instituter,as required by Section
of Bc laher Code,for the k rmornm m of Ne work for which Bis permit is issued.
WoJt�r's Compensation Insurance realer and PnGcy`t�am?r,re7ier. a•✓L RTIF /�ATEOF l IAL+Policy RO K Y
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
prie section need not be completed if the Permit is for one hundred dollar.,(5100)
,it Icss.)
I cenify that in the arformance of the work for which this permit is issued,I shall not
employ any person in any mound sin as as became subjet-uo the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IT after making this Cenificare of Exemption,you should
become subject to the Workers comic matron provisions of the Labor Code,you must
z forthwith comply with such provisions or this permit shall he deemed revoked.
OCONSTRUCTION LENDING AGENCY
1 hereby affirm that here is a constitution lending agency for the performance of
Lv work for which this permit is issued(sec.3W7.Civ.CJ /1
QLc bender's Namc
IL z Lcmdcrs Address
C) 1 calmly that 1 have read this application and sure that the above information is
Hconed I agree to comply with all city and county Ordinances and seats laws relating to
V building construction,and hereby authorim representatives of hts city to enter upon the
G above mentioned property for inspection Purposes.
(Wagree to save,indemnify and charmless the City Of Cupertino against
rA liabilities,judgmcnu,costs and expenses which
may in any way accrue against said City L/
,Z in consequence Of the granting of this Permit. /P�
^' APPLICANT UNDERSTAN S,ND WILL C PLY /•IN Issued by:9412�(a Date
SOURCE REGULATION
Re-roofs
Signature of ApplicariUConmaci n Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or ruler.building occupant some Or handle hararduas material
as defined by the Cupertino Municipal Cods.Chapter 9.12,and the Health and Safety
nor,Scent 21111(4z--'-0
5532( All roofs shall be inspected prior to an roofing material beim
❑YeaNe P P Y g g installed.
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
7nia
ha'ramnes air comeminams as defined by the Bay Arca Air Quality Managcmcnl all new materials for inspection.
ict?
❑Yes No
1 have mad the havardous materials requirements under Chapter 6.95 of the Califory
caW&SafetyCove,Sc otum,2551515533 and 255]4.1 understood hat if the building not cuoxrmdhave Ian BatiI s my mthility m notify the occupant if he
iremcnu len tMmal tore(, au prOcronancd Signature of Applicant Date
a 1
Owner or aumnrixed agent Dat All roof coverings to be Class "B" or better
10/07/2003 00:25 5105383262 LEGALITIES INK. PAGE 02
CITY OF CUPERTINO � i��
� (e FURNACE/AC
CUPEkTINO PERMIT APPLICATION FORM 03/ y9
APN# 3 //^ CZ� �� Date: ` /7 D
�G' �l 3
Building Address: /�/32
9 Cc
Owner's Name: � Phone
.COntC or: Phone: License #:
ContactC/,'� Phone: Cupertino! $usiness License #:
Building Permit Info:
Bldg O Elect ❑ Plumb ❑ Mech
Job Description:
c.�e.....� r—la — 70, 0 O O
Residential Commercial Fl
For R idential Installations:
attic l" floor ❑ 2nd floor❑
dhere to min set back requirement El
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:
/CPS D • D-b
Strapped On Platform D Bonded ❑ Sq.Ft. Floor Area:
New Location ElReplacement Y t
Qty. if
Applicable Fee ID Fee Description Fee Group
I BENERGX Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm I MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMII'FEE Mech Permit Issuance MECHANICAL
PPERIv11TFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Peart Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING