00100050 (2) CITY OF CUPERTINO
Buu,mnG DIVISION PERMIT CONTRACTOR INFORMATION:
(WILDING ADDRI55: - PHRMI'I'NO
OW'NI:R'S NAMIiAPPIACAHON I�Q}, 'ef'600 J0
1199 STAFFORD DR ATLAS HEATING �[ l1.
[ONE;. Y
DAWSON PERCY M AND TERE. A 155 SAN LAZARO AVESANI'rAitY NO 1.0/06ON/��I��t
G neo O ARCHi rECrdiNGINEER: BuILD1NG for.1 T INFO
x (408) 739-0516 01DG ELltcl' PLI1610 Mesa
Niw I-J L_ I-J I=1
1v
Nj LICENMIDCON'red under p DECLs of Chapter
Job DL'SCflptlOn
I hereby ntrirnn that I nm 0 thecd under provisions of I,Caul 9(commencing
11, n
OyNG Bios
C with Sadun 7l)WlnfDivhlnnJ of the businms and Prnfcs,ion,coda..nA.dy llcmnsc .
s in lull force wd e11�t ,.`
n aol a I,Icenm C�l.i�y w /
°'O ad O Uatc ILI��sZ� Comms or
F a ARCIII'rECYS DIiCLARATION AC ✓
I I .I 1 Y PI MIM. d'. 1 hl nln
anep� lass IP f1
OWNIH RUIIDI?R DI CI ARAnON
WF' 1 hereby B N t 1
5I' f N I nx Lorena law for the
ouia 31 5 Hioiavoii l .' ..C y r
re winchreq esIermittconstruct. I•r,amp J ixh,orrepfrany structure wprior I issuance.
-
y
requires the ampficarlfor such permit file g Jaawment
bar he 1......old p,.ria tl he n n, I he c arachn,1 I.aw(Cnl.pm-,9 Sq. Ft. Floor Area , Valuation
(commencing with Section 7088)of Division 3 of the Business and Professions Code)
nr that he I,isen.pl lhemfn.m call the basis tin the idlecal cxmnptior.An,violation
of Section 7031.5 by any applic0nl for a I.cnu n sti jcct,the opplicanl to a civil penally
of not.core than five hundred dollars($500) APN Number - - Occupancy TYA
01,ax owner of the pmpeny,or.ny employees with wages 0s doeir,ale compcn,ramn.
will do the work,and the,tnmmre is not imcnded or olfered Iia s d.(Sec.7044,
Ermine,and Prares,inns Cone:Tine Common,.unan,e Use doe,ren apply h..... R fired Inspections
„der ofpmpeny Who nudds or improve,thereon,and who dues such work himself 3621 1028. It�_
nr 11,I.ugh his own cnnployces,provided thill xucb i...pmvemen.,are not imcnded or .
offered(orals.11,In.wmsr,the building or improvement in sold within one year of
ttnnplmion.the owner-nuilAcr will h:vethe bnNenofmoving battle did not build or T�^ _ ROUGH MECHANICAL
impmva for purn,,01'x'alcJ. J J
0 Lao cosucr Ill tire piawrl>.: ,exclusively contracting w all riamvd
ecortaclors 304' — ROUGH ELECTRICAL
n
construct Theaw project(sec.7Wy Business and Prnlc hob hNoCodr The improves
fincnors
license Law draw nm apply m an owner t property who bands m improve,Nereoa. 505 — FINAL ELECTRICAL
Cm who e..nnmrn,tor,rie1.nn,;lets wire u ea..nma.o.rxl dea..wd h..maann m the 508 — FINAL MECHAN I CAI_
Coi lreI exci I-icer,Ww.
❑I nm cxc.npn under Sec. .H k F C lin his reason
Owner Date
WORKh R'S COMrENSA1JON UBCLARATION
I hereby affirm under,pcnallY of perinry one of the follawine declaration,
'31 have and will maintain a Certificate of Consent m mlLinstm for Worker's
Cnnliem.tiun, as pmviJcd for by Section 3700 of the Labor Coda for he
perfann0aec of the work tot which this pandit is leaned.
'g3.91 have and will maintain Walker's Conrpen,mlon Invmance,as required by Section
3700 of the Latin Come,far the performance of the work for which this permit is
'wed,by Worker'x Cnn.pecouninn Insurance cooler and Policy numM�r are
CanicrG— CRF s Policy No, C17�� 1'la
CIJfrIIICA'fIDN OP I3XEMr13ON FROM WORKERS
CONEIIiNSATION INSURANCE
frbi,nation need dol be cnnnplond if the pernal ix for one hundred dollars -
(Sllallorless.)
I certify that in die performance of the work for which Wiv permit is issued.1
,hall not employ.cry tmrson in any n.nnner so as 4.become subject to the Worked'
❑in,m0tion Los,Ili California.Date
Applicant
NOI'ICi7'r1l AI'I'LICANT:11:afro.making thix CcniBcu.c of Exemption,you should
necnme subject o.the Worker'.Compensation pmviwo,,of the labor Code,you mom `
Q fnnbwhh comply with,rich pro...am,or Ibis peram shall be deemed mocked.
L CONSTRUC'nON UNDWO AGEMY
5" I hereby Intimt that there 1,a construction lending agency for the performance
of Ihc work for sv'hich this penin is issued(Sec.NN7.Civ.C.)
41s Lender's Name .
C Z l.eader's Address
t..t 1 lenity that I have rcud Nis application and nine that the above infnrmalion is
fi [r onmcl.I agree In con.ply w,It n11 city and—any ordlanncw nod,tate Iaw'relining
Q V mbu1J g n cf adh hy' du p tmivc, fah'.city 1. n¢rurym
�,. CL. the h 1 1 p p 1) d
O. (We) g t c rid nn,a keepwhich
h4 d :the wit f C pen cog.laid
0 (inti I'1 1 Jg r e d pe . i h h Yin any Y 8aina.nW N
(> Z City I wNT U rte t the N t b f Ni p I
APPLICANT UNDERSTANDS AND WII.LCOMPLYwRf1A hNP/�I ISSUCd by: Delo
S U tEGULAT ONgg. IJ11//
rLeO� O
Sib lure of AFplicam/Cunmamm �6 1 .m — Re—roofs
HA9AR000S MA'Iai1tIALS DISCLOSt tE
Will the applicant or future Wilding occupant,lreeorh.mdlehuamousmateti:u Type of Roof
as defined by the Culnrrmo Mnnielpal Coda Chamcr 9.12,and the Health and Safety
Cale.Section 25532(0):' -
OYes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building weamatnt use equipment or devices whim If a roof Is installed without first obtaining an inspection, 1 agree to remove
,,it hur,udoux:or cannuninanw as deforest by the Bay Arca Air Quality Management
attar I all new materials for inspection. Applicant understands and will comply with
0Ye, 0 N all non-point source regulations.
L
e read be he.hima,matenul,regWremmns under Chun,,6.95 of Ihc „
health k Sarney Cala,Seniom 25505,25533 and 25534.1 and cnland that
n,oce,nm emrendy have.nenanl,thin it it my rc,pnm rid toy.o nodi l y.he
the requirements which.must bel mel prior h.issuance of a Csnificate of
Signature of Applicant Date
thmi,<a agent - Dale All roof coverings to be Class `•B" or better
t