04070032 (2) CITY OF CUPERTINO ,
BUILDING DIVISION PERMIT• IC�NTRAGTUR,, INFORMATION x; -
3
BUILDINGADDRESS: ATLAS HEATING PERMITN004070032
OWNER'S NAME: FERM)TLSSUBDATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
>0' LICENSED CONTRACIDR'S DECLARATION O O O O
9� 1 thereby"M than 1 Am licensed under previsions of Chapter 9(commencing Job Description�Q
with Section 70110 of rvu 7ofihe Rau Prof op�C and y1' a
"'� '"`du a andJ1�� REPLACE FURNACE & ADD A/C `�1
L�Z License Lle.g
q Damcamrxwr J/r� �.
7 cHi GI's DEC. U
? U IunnJ p n, h M�pcd asP a 2004
u. wensc.Pmm,como l
ap� OWNER-BUILDER DECLARATION
I hereby a(fen that 1 am exempt from the Conwcso's License law for the
00 following=man.(Section 70 1.5,Business and Professions Cada:Any city or county
3 fi which requires A Permit ar mmaruci,aims,improve,demolish,or repair any snucsure -
H y prior to its issuance.also requires the applicant for such permit to file a signadsmmmenf
x�< that he is licenmd pursuant to the previsions of the Contractor's License law(Chaper 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7")of Division 3 of she Business and PmfcuionaCade)ar
y mos be u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7071.5 by my applicant for a permit mbjecumc Applicant a A civil penalty of 32�ffi-J'bI�Gr00 Occupancy e
.or mase the five hundred dollars($5W). P y Typ
1,as contractor the Pmpvty,a my employees with ways as their rale compensation,
will do me work.And thuwnure is not intended or a@ for sale(Sao 7014,Business
and Proleraions Cade:The Contractors License Law does not apply to an owner of Required Inspections
prapeny who builds or improves thereon,and who does such work himself or through his
awn employes,provided Out such imp asve.an s arc at intended ar Offered fartela.If.
hawem.the building or improvement is told within one year of compledan,the owner
builder will have me human of proving that he did not Wild or improve for purpose of
tela i.
❑1,As owner of the progeny,am exclusively contracting with licensed connections to
construct me Project(Sec.7064.Business and Profexuom Cade:)The Comnemrh U.
come law dos not apply to An awns of progeny who Wilds or imprmm memon,and,
who contracts for such projects with a contramKs)Humored pursuant in IM Comracsors
License Law.
❑into exempt under Sec. .B k P C for oris wan
1371W
wner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of the following dalantions:
I have and will mainuin A Certificate of Consent to self-insum for Worker's CnmPcn-
tian,u provided for by Section 3700 of me labor Code,for the Performance of the
rk for which this permit is issued.
1 have and will mainuin Worker's Compensation Insurance,u suired by Section
of the labor Code,for me perlarmace of me work for which this permit is nuu i.
y Workers Compensatio sunny c 'v and Policy numer are:lPolicy No.: m.T J}
✓% IFICATEOFEXEM a" FTlO RKERS'
COMPENSATION INSURANCE
(Tho it..need nor W completed if the permh is future hundred dollars(SIM)
or less)
1 mainly that in the perfmm.nce of the work far which this permit is traded.I shah nos
employ any petaan in my member so as an become subject to the Workers Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,arm,making this Cenifimic of Exemption,you should
become subject to me Worker's Compensation provisions of me labor Code,you must
.J0 forthwith mrandy with such mond...or this Permits hall W dreamed revoked.
z., CONSTRUCTION LENDING AGENCY
I hereby alRrm the Nett is a construction lending agency lot the performance of
CC the work for which this permit is issued(Sec.7097,Co.C.)
Ig1 Q
Le'
dcrs Name
Z Landers Add.
U 0 1 cenifY that I haus sad Ws application and sum that the above information is
H cancer.1 agree to comply with all city and county ordinances and sum laws relating in
DUbuilding construction,and herchums
y..,had.topic of this city to anter upon the
W ahovcmemioned property for inspection purpoer.
CL (We)Agee to save,indemnify and keep hssmlers me City of Cupcnino against
llabilities,Judgments,costs and expemu which may in any way acerae against said CHy
U Z in consequac the grant. of tis".I
AI C7T
^ 'APPa'o A DERST DS AND WILL CO Y WITH ALL GN701� Issued by: D [E EG LDIRe-roofs:gnat f c Can to
DOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building=open,atom or handle husa dous material
aaaalau defined by the Cupentno Mu Igen Code.Chapter 9.12.and the Halm And Safety
ada.seetian25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will the applicant or fu um Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous...emasn inan defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea e
I have mad the mamrialsmquimments undcrCMper 6.95ofineCalifor-
m.firal"Sal aAAMM5,25533emd255XItsiderreadmmiftW Wilding
dam nose y t,mm it a my eap°nsihitity m notify the oat ant oLme
myuimmcnts h' t artaofaCertifcamofOeq y. rti
Signature ofApplicant Datewncr m am
V All roof coverings to be Class"B"or better
- Community Development
10300 Torre Avenue
u Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
_fUPERTINO
t entr
JOB ADDRE f OC` Lo ,
LIZ Ockk- S�t - PE uu32
OWNER'S N T ! .k k PH ffO -I 124
GENERAL C CTOR: 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 s a 1�
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
U
r/Contra Si D to
sotv-�
CITYOF CUPERTINO
FURNACE /AC a CF o 03
CUPERTINO PERMIT APPLICATION FORM
APN # 0 Date:
Build1,34d,¢r J: LU
Owner's Name: Phone
QUn 0 3 - Y
Cont tgr:, i r Licens #:O G f
37
Contact: Ph ne #: O o 1
e T 2S 3 -G �
Applicant/Contractor:
Building Permit into:
Bldg ect Plumb ec
Job Description: Cr
Residential: 1 �� �(�� add Commercial:
Sq.Ft. Floor Area: !Valua
Architect/Engineer: ion:
Type of Construction: up:
Qty. ikl
i a le Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
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 BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC I Business License BUILIDNG