00100094 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
ROILIANGADDR7'332 KT.RWIN LA ATLAS HEATING PERMIT No. 4)0700094.
OWNIarSNAME - 155 SRN LRZRRO' AV °PPI.ICAI ONSUJV71.L/2000
DONEZ
PI IONS: (408) 739-0516 SANITARY NO. CONTROL NO.
G rc Z ARCH[TEC iENGINEER: - BUILDING PERM]P INFO
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m_ BLOC; Ed 1'1_I ILUN1N SPEC
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LICENSED.CONTRACade,pr DECLARATION Job Description
ZO S v_„ 1 hereby mEnn that 1 an,Ilean.wJ under provisions of Chapter and
nmanense
1=E5Z with s«Iran]aldeffirdxior,3onheea.mr.xandProre..innsc,u andm>airen REPLACE FURNACE ADD AIR CONDITION
zx ,.In nal erre and erce
u OO n U '<uuc class �_ Lie.p X165 _�
Unm GnI1CLA
AHCH ll he ue DECLARATION / /
3LL •
s-LLO J 1understandray planshall he ❑ 'publicJ. •
Oar I OWNER-BUILDER Ill It DI CI Contractor
o LL ng so II on I eines Ili C I t de La 'for Ny
h Z folkaw g h i ]1111 S E J P 1 :Cal:A lY county O
o when requires a Penni)to consumer,vers,improve.demolish.or repair any:ituemre
a3. prior to is i.cnnnce,ahs requires the applicant liar such)+amino file a signed sr:nemem
an he is licensed pnatima. he,uo,,,ms of NC Connector',Licxnso Law)Chap",9 Sq. Ft. Floor Area Valuation
mannnsencing Win Section]Oap of Division Sof use Ht inrss and Prnfc cions Cock) �1
or that he is exempt therefrom and the basis for the alleged exemption.Any vinimion -
of Section]031.5 by any applicant for a pem+it subjects the applicant h+v civil Penally
of Fol more that five hundred dollars 1550p. _ APN 1?umb�r.00 �� Occupancy Type
❑1.asnwnrt of the turn, w ins with wr res as rhrlfsole cots don. 3"e3 t_.
pd dre structurewill is notintendedor orcene for sone IScc.num+.
Resines and Prolcsmons Cole:The Contractor's License Law does and apply m+an 1 e n e I 15
owner of property Who nuikk or improves donvon,and,who does such work himself 301 — RVUt]t"t' IIIrI�t�IVG
or Nnmgh his own employees. ouvidcd That such in+p...Womms are not amended or
ollered for.nae.11,bmwcvcr.the building or improvement Is sold within one year of 303 — ROUGH MECHANICAL
omplction,the owner-builder will have the burden of proving that he did not build or 304 — ROUGH ELECTRICAL
Improve fm pnrpuso of sv1ed.
Q 1,a%owncr ol the property, int exclusively counseling wilh laccused contractors It, 505 — FINAL ELECTRICAL
Imorsel he projrel(Ser.nus.Rosin.ural Pmfe..imt,CodcJ'I lie Cmnraid'a" 507 — FINAL PLUMEING
do,"a L+w does not apply to an ower,of property who nwldv or improves duration,
and who contract,for such project,with a contractors)licensed pursuant m the
C 508 — F 7 NAL hIECHAN 1 CAI_
omranor's Licansn Lsw.
rl I um exempt under Sea. ,P A,lie int this reason
Owner Dam
WORKER'S COMPENSATION DRCIARATION
1 hereby affirm under Penally of perjury one of Ne following declarations.
❑ 1 hexa and will maintain a Certilieme of Consent to self-Loan I Wnrkcr's
Compensation, as provided lin by Section 3741 of the Labor Code, for the
performance of the work for which this permit is issued •
El I have and will n onion Worker's CmnpemmimI le,orm,ce,as m,nimd by Section -
37001 or the LaMa Cada fat the performance of the work for which this�permit is
ed.My Worker',-Compensation Inwranee omnia and1 Policy member Y
Currier: Qyr-� Polity No,
CERT IFICSIION OF 8%EN 11 ION TROM WORKERS'
COMPENSAFiON INSURANCE
npui section need not he completed if the permit is for one hundred dollars
1E lap in Ices.)
1 enit,Nur in the pnf ranee ol'the work lot which NIs permit is issued.I
shall not employ any person in any menncr sn as to become subject to the Wnrker.0
Con,pemation Laws of California.Date
Applicant
NOTICE1'0APPIACANI':11:alter ranking This Cer ilicute of Exemptinn,You should
......
u"'Ines)In nm Worker's Cmnpansahnn p-vipionh of Ne I.unnr Code yon unit
Q Q lire nh comply with such provisions or this person Qmll he deemed revoked.
z ^ CONSTRUCTION LENDING AGENCY
> 1 herehy atllen that there is it cnmlmction lending agency for the pedominate
urlhe word,In,cluch(his pcm,i,is I......I(Sce,3097.Co.C.)
L Q IsnJer's Name
z IsnJer's Address
U0
1certify that 1 have read this application and state that the above infuriation is
E..
kis co acct I agree It comply with all city and county ant ares nod one laws relate,
Q J mhiilding codsvuninn.and knehyarflu xere"o"' adwo,offid shy m enter spm,
} [a] the vMve-mrntinmd,sm,dy for inspection purposes.
(Wc)agree to save.indemnify and keep harmless the City of Cupertino against
t,,, Oh liabilities,judgments,costs and expenses which may in any way accrue against said
U z Chy L f Nu wag of Nix pcnnit. �j�
^' AI' .I(\N DERSL U ANDWII . .)MPLYWITHALLN N-W]INl' IssuedC _ Date
URs'C\ISI IM�fs L TION ( Lr�-o��eo Y'
`\ e ett
Signawrc of App�lta Convector Dale Re-roofs
HA%ARDOUS, ATERIALS DISCLOSURE
wul d,capphrnm of rmure���dingaemam coramhandle hnru�dow.-,medal TYPe of Roof .
ac JelineJ by the Cuprnina Municipal Code.Chapter 4.12,and the 1{euhh and Safety
Cada Section^-5532(a)"
O Yes 0 N All roofs all be inspected prior to any roofing material being installed.
wnl "'m...canorralare but pJingoreup:+m:tumrquipmemmde.ica.wl+701+ If a root is installed without first obtaining an inspection, I agree to remove
-,nil haeurJrm.v air can't
as ddinrd by the Ray Ass Air Quality Management
Oiswce all new materials for inspection. Applicant understands and will comply with
tern ON. all non-point source regulations. '
I have rcuJ Thr 1111 nus Inumriuls rcquircnmms nndcr(:hupwr fig$or Nc
California IIcvIN&Solely Cndc.Sections 255(15,25533 and 25534. understand)lira
if the ilding does nal currently have a normal.that it is my m%,novibil by m notify the
oe a d•-qui-, c n,�which musp�ran prim m isswncc ur a Cenilicate of
r C0�c 1 1 1 11 1'f�li/1 ,f ��,� Signature of Applicant Date
n"o�antlr+t rd gXNI,C.�t `VTC Dale All roof coverings to be Class "B"or better
OFFICE