04110006 (2) CITY
I BUILLD cDIVISIONNO PERMITCONTRACTORINFO
RMATION _.
BUILDING ADDRESS: PERMIT NO.
ATLAS HEATING 04110006
AM PERMIT ISSUE DATE .
NE: - '" SANITARY OL NO.
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a00 LICENSEDCOMAACTOR'SDECLARATION _ Job Description
P I Mmby affirm that 1 am licensed under provisions of Chapter 9(commencing
sew wiNSeclion700O)of Division3oflhe Baurc udR fauiom Code.andmyliceneis .
^ w in full force and affect.
j�_ Lianse Clas L'e.X WALL HEATER REPLACEMENT
,;:Q Dam Contractor ,
ARCHI'IFCI•S DECLARATION
ji z I unwwand my plans shall iw dud u public Iecnrda - -
''o G LiccnuJ Pmfcuionel v
` g OWNER-BUILDER DECLARATION
<� 1 hereby.Taco that 11. exempt from tete Comns Co e:Any C Law for the
p o following uiresmason.Permit
i )(131.5. t.altar,
and are.dcdamp Calc:Any city m county /
x
.10
�+ which requirex a al m canstru0.plan improve,demolish, fi repair any umaure
'e y thatpoinOr its issuance.en dpons r mQo ersthe Rhm roviam applicant for such Contractor's
is Lim m Law(Chapter
eel
that he is license)pursuonlm the previsions of the Comncmri License law(Chepter9 Sq.Ft. Floor Area
WWAS (commencing with Sation?")of Division 3 of lbs Business and Pmfessm.Code)or
y _ that he is eumpt therefrom and Ila Eau for One alleged exemption.Any violation of
Section 9031.5 by any Applicant for a permit subjects the applicrot to a civil penally of ,.ftffgbigkser --• Occupancy Type "
not mon man fire hundred dollars($500). 3 7't Y17 UY1,7". 0 0
1,as owner of the property,or my employees with wages as their sole compensation,
willda the work.and thesBucure is notintended oroffered forsade(Son.9614.Business ns Required Inspections
and Professions Code:The Contrecmrs Li.Law d.rat apply a an owner of - q P
pmpeny who builds ver improves thereon,end who docs such work himself ver through his
own employccs,provided that such imPTOWWOu m not intended or offered for We.IL
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 improve for purpose of
.[a.).
❑1,as owner of the property,em exclusively contracting with licensed contracmrs an
construct the project(Sec.90x4,Business and Professions Code:)The Canvacar's Li-
aeae Law dans our apply in.n owdef of property who Ulllds or improve thereon.and -
who contra¢for such pmjecls with a commctods)licensed pursuant o the Contractor's
Licenu Law.
0am eaempw/n�Ief�SS��am. ,B&PCfor this reawn
ow�!�,[�___,�i m D
�;V66RIcc��((S IS
thereby. irmundcrpcnaltyof,..S,.yoncafmc 11 1ngdMvatians:
I Id.n and will maimuin a C.o fia.off of Cosa.m self-in um for WortdsCompcn-
rauon,as provided far by Section 39W of me Labor Code,for the performance of the -
work for wM1ieM1 this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section _
3900 of the Labor Code,for the Performance of the weak for which this permit is issued.
My Workers Compensation Insurance caries and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
f@u section reed not be completed ifthe Permit is foredo hundred dollars($100)
Icss.)
I cenify mat in the performance of the work for which this permit is issued,1 shell not
employ any person in any manners to to tecome subject to f Workers Compounded
Laws of California.Data
Applicant
NOTICE TO APPLICANT:Ir,arm,making this Ccnifcate of Exemption,you should -
become subject to the Worker'&Compensation provisions of ft Labor Code,you must -
.JO fuMwuheomplywith arch prevision or this pc.transit be decreed revoked.
Z" CONSTRUCTION LENDING AGENCY
Fa vN_. I hereby affirm that them is a construction lending agency for the performance of
x Iltc work fur which this permit is issued(Sec.3097.Civ.C.)
r[7 A Lender's Name
U z tender's Address
U O 1 cenify that I hast read this applicrron and sum that the above infolmauun is
II. F-' correct.l agree to comply with all city and county ordinances and sum laws relating to
0U building continuation.and hereby authoda represemntiva of this city to enter upon the
41.1 alar&mentioned property for inspection purposes.
(War agree to save,indemnify and keep hamllcu the City of Cupertino against _
F� Iiabilida,judgments.costs and .,.which may in any way accrue agernsl said City fll6;:
U Z s pandrit.
APPLICANTCof due lotamIng Of UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 1
SOU EREGULATIO - '/
/ /IIiP/n �f 1f Re-roofs
S nf��n�� V ver
./ HAZARDOUSMTERIALSDISCLOSURE Type of Roof
Will the applicantauorfmurebuildinge,Chapter
tsmrc or handle hazardous
and
az defined by dte Cupertino Municiryl Code.Chapmr 9.12.and dte Halm anti Safety
Cade.SectiYoes L(Nun 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or furaesu equipment building occupant eseqme
uipnt ver devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
islrict? L��
QYa p.
I have mad the haradiduSstha erial&requirements udJerchapter 6.95 of the Calimr
niaNalth&Safety Code.Sections 25505,25533 and2553<.lunderrand lhatiftlte building
data nml eurand have a mnan�Nat it is my mspearbility a nuuly Ute acupaml of thc
require ts-whtchmost hemet poortoissnanceoraCanramofOceupaney. Signature of Applicant Date
o aammiae `/� Dave All roof coverings to be Class "B"or better
Community Development
£ �'M 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�.UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
� 4 l ifs G 6
O R'S NAME: NE # •-
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
O�Wr/Contractor Signature Date
CITY OF CUPERTINO �-
_ CITY OF PERMIT APPLICATION FORM
CUPEkTINO
APN# 3� 1 / v /-3 Date: / i:f-, 2!P- U
Building Address: 2 1 e93 5- z- Mailing Address (if different from building address):
Owner's Name: e#: i
Contractor. / Licen
Contac . hone: $b^ Cupertino Business License#:
.,- Fax:' ?
Building Permit Info:
Bldg le ❑ Plumb ❑ Mech ❑
Job ascription: /
Residential ❑ v CorpmerciaALeikoLot4�6
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this bo 'f the pro' is a
A 11k second-sto addition:
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group ,
BAPPLOTHER .Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
_ BCONSTAXR Constax-Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
CUPEYOF PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUP TOF Yo PERMIT APPLICATION FORM
Quantity Fee ID Fee Descriptio'n Fee Group
BREMSIGNAD Rmdl Signs Add Banch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Ternp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot _ ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
-_ MPERMFEE . Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE_ Plumbing Permit Issue _ PLUMBING
._- PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG _ Address Chane BUILDING
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