03110131 (2) 1-CITY OF CUPERTINO > • �+�•� a y" n"�'"^�'�°'
BUILDING DIVISION PERMIT °t:.CONTRACTOR INFORMATION "'
1DUILDING ADDRESS: ATLAS HEATING PERMIT NOO 3110131
0361 ORANGE AVE
OWNER'S NAME: PERMIT ISSUE DATE
AUL WHEALLEY 155 SAN LAZA AVE11/21/2003
i
ONE: SANITARY N0, CONTROL NO.
(408) 739-0516
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 1�
l0, LICENSED CONTRACTOR'S DECLARATION Job Description
YC I hereby air,,.that I am licensed u r provision of Chapter 9(commencing p
F with Section 7")uf Division 3 of NCD nese and Profeuinm Code,and my license is
in toiZr.�e andeFevt, FURNACE REPLACEMENT ,
- Z LicensAj7as _y- Lu, 0 (3
p
Data C��nuac,�toor
ARCHITECTS .CLARATION
f U icuund my plans shall the used Wu public=car&
C.
h0. Lkcnsed Pmfcssinnal
�q 5 OWNER-BUILDER DECLARATION
A�S 1 botchy affirm(hut I em exempt from the Contractor's License Law for the
following reason.(Stenon 7031.5,Business end Profession Code:Any city or county
which mqutru a permit to consumer, he,,improve,demolish,nr repair any s0ucluos $2000
Zi prior to its issuance,also requlmsthe applicant for such permit toff a signed six menI
s�FF that he is licensed pursuant to the provision of the Conrrulori Liense Law(Chapter 9 Sq. Ft. Floor Area Valuation
2 $ (commencing with Section 7")of Division 3 of the Business and Professions Cade)or
tt that he Is exempt there(mm sad the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permlt subjects the applicur to•Civil penalty of 3 WPUK erO0 Occas
not more than foe hundred dollars(SSW). Occupancy Type
1-1 I,a ownu of the pmpcny,or my employeu wlN wages u their vele campenutlon,
will do Newark,and the sWcmrt is not intended oro0ered far sale(Sce.l09A,Business
and Professions Code:The Cmu actoh License Law docs not apply to in owner of Required Inspections
property who Wilds or Initiatives thereon,and who does such work hi..)(a,duo gh his ,
own employees,provided Nal such improvements anent Intended Ordinal for aplleB
however,the building or improvement is sold within one year ofcompledon,Ne `cr'• •I ' - DE ,builder will have Jm burden of proving that he did not build or improv for pu ofsale.).❑I,n owmr of the pmpeny,am eulusively contracting with licensed con ionn-
contact Ne project(Sec.1614.Business and Profession Code:)The Conine a Li.
cense Law dura not apply to an owner of property who Wilds or improays there .sadwho contracts for such projects with a contranor(s)licensed pursues to the Canbrg'License law. ""
❑1 am exempt under Sec. ,B k P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
I ban and will maintain a Certificate fComma to elf-imam for Workers Compen.
satlon,as provided for by Section 37W of the Mbar Code.for the performance,of the
work for which this Permit is issued.
El 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of NC Ube,Code,for the ferformmce rf Ne walk far which this permit is issued.
Y Wolker.Charlie..e pp.Imo race prier and Policy number+GR:
r. P I' No.:_I78OIcus-O3
CERTIFICA FE)(EM FROM WORKERS'
C PENSATI INSURANCE
(Thu suction need nor W completed if the Permit is for one hundred dollars($100)
m less.)
1 certify thn In the p ohmaance of the work far which this permit is issued,I shall nut
employ any person in any mennerso as to became subject to the Wrrkeri Componstlon
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cmificete of Exemption,you should
become suhjecl to the Worker's Compensation prevision Of rim Labor Code,you most
.Jz forthwith comply with such prevision or this Permit shall Is,deemed revoked.
ti O CONSTRUCTION LENDING AGENCY
1 hemby Affirm that than is a conuucnnn lending agency I'or the perfurmance of
x � W work fur which this permit Ls issued(Scc.3097,Civ.C.) -
V]Q Lender's Name
=z Under.Address
L)Q 1 cerdfy that 1 ban read this application and sate that the$,taw information is
Ua Fcarted 1 agmea m comply with all city no county ordinances and sum laws IoW ng m
O V buildingconwction,analherebyauthorimreprsentativesofthiscitytoenteruponthe
W ahavmme judgments,
propertycosts
for inspection purposes.
g), (We)agree to saw,Indemnify Nd keep harmless the City of Cupertino again$,
fiabilZ incoinesrience fthecountingofPemeamit. may in say way accrue against said City
Uz ineonsequcnec NDE114TANDfthis permit.
APPLIC UNDER TANDS AND WILL COMPLY�F�FI ALL NON-POINT Issued by: Date 4 r
SOURC R ULATI S 1 , nn/ ✓ /��
annuof Appbcan oname r `Y
m I Data Re-rpofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupantamm Dr handle havardous material
defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
cele.soman 25532(a)? ```��1 All roofs shall be inspected prior to an roofing material beim
❑sen Lpa p p y g g installed.
Will the applicant orfuWm building=upon,use equipment ordcvices which If a roof is installed without first obtaining an inspection,I agree to remove
it halmat s air contaminants u dcMcd by the Bay Area Air Quality Management all new materials for inspection.
ittrict?
❑Yes ,�a
1 haveread thc hnardousmamrois requirements under Chaptar61l5 of the Califor. �
ria Hea W lk SafetyCmc,Section 25505,25533 and 25534.L undcmand thatif the Wilding
does not curcndy ban a nano Nat it is my aspera hiliry to nodfy IM occupant of the
myuire ichor erpoor toiuumaoraccoi"ca¢ofap.ncy. Signature of Applicant Date
nor or autho mixed agent Dam All roof coverings to be Class aBn or better
CITY OF CUPERTINO
FURNACE /AC
CUPEI�TINO PERMIT APPLICATION FORM
APN
- 15 - ()03 Date: � I ap 03
Building Address:
f 05 r e
Owner's Narr�,, ^ ' Phone # \
Contractor: License#
t s S �8 t3�
Contact: ^ Pho
:
Applicant/Contractor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: (� n
Residential: T 1`� I� r atm Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
• Type of Construction: O. panc I, roti
—
jae Fee ID Fee Descri do Fee Grou
RGYEner BUILIDNG
FURN Relocation of Furnace MECHANICAL
ACOVER A/C Unit > 10,000 cfm MECHANICAAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
RECEPT Rec tl, Switch & Outlets ELECTRICAL
MICRE Seismic Fee Res BUILIDNG
MITFEE Elec Permit Issuancr ELECTRICAL
MITFEE Mech Permit Issuanr:; MECHANICAL
PPERMITFEE Plumbing Permit Isst.; PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG