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03060151 CITY OF CUPERTINO ° * -° BUILDING DIVISION PERMIT 9CM0NTRACTOReI NFORMATION $ au1LDINGADDRPSS: ATLAS HEATING PERMIT"°03060151 OWNER'S NAME: 155 SAN LAZARO AVE PERMIT ISSUE DATE °NE: (408) 739-0516 SANITARY NO, CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 lea LICENSED CONTRACTOR'S DECLARATION lob Description 1 catchy affirm that 1 am licensed under provisions or Chapter 9(commencing ^¢ with Section 71XKl)Cr Divhlon Sof Ne Busincumd Profcaions Cede.and my license is < infullfooeond kZ0 LIC." RELOCATE FURNACE, WATERHEj� ., y Z License Clan '((—�'�v Dam /t Comramr e ARCHMass nECr DECLAR O e I understand my plana Mall he used u public records J U L 0 7 2003 s a C� Licensed Profeaaranal g OWNER-BUILDER DECLARATION B�q I hereby affirm that 1 am exempt from to Contractor's License Law for the BUILDING aL®'�� 02 following rtune.(Section 7031d,Business and Professions Code:Any city or county 477 5$fvi which requires a permit to construct.almq Improve,dcmolixh,nr repair any muctum poor to its lauancc.also requires be applicant for such rental to Ne asigned statement pZ< that be is licensor pursuant to Me provisions of the Contractor's uccom Law(Chaplet 9 Sq.Ft. Floor Area Valuation (commencing with Section 1000)of Division 3 of the Business and Profession Code)of .. that he is exempt thcrtGom and the basis for the alleged exemption.Any vialmon of 35620006 . 00 Section 7031.5 by any appimantfor a permit subjects to applicant to a civil penalty of APN Number Occupancy Type not more Nan rave hundred doll..(5500). ❑I,u Owner of the property,or my employees wit wages u rhelnale cumpmullon, willdotework,andtemuctumisnolintendedur.frmnifouale(Sm.7044,Business — and Prefestiom Code:The Com en's License Law does nut apply m an owner of 303 - ROUGH property who Wildsor improve Neremn,and who doessuchwmk himselfortrough his own employees,provided tet Inch improvements me not intended or offered for sale.It, 503 — FINAL MECHANICAL ENERGY however,to building or improvement is Cold within one year of completion,to owner. builder will have to burden of proving tet he did not Wild or improve for purpose of 508 - FINAL MECHANICAL talc.). ❑1.as owner of to property,am exclusively contracting with licensed contractors to contract the project(See.7044,Business and Rotations Code:)The Contrames U- ..Law does nal apply man owner of property who Wilds or improve temun,and, who contracts for such projects with a conuaaar(U licensed pursuant in the ComncmM1 - License law. ❑I ant exempt under Sec. .B A P C for this mason Owner Dam WORKER'S COMPENSATION DECLARATION ' 1 hRum ereby aunder pcmlly of perjury Oro ow of to following declarmom: I have and will maintain a Certificate of Consent to self-Inure re for Wokefs Compe cation,a provided for by Section 3700 of to L W,Code,far the perfmmence of the work for which this permit is laved. 1 have and will maintain Worker's Compensation Insurance,u required by Section 710 of to labor Code,far the performance of the work for which this petit is iaued. y Worke//t��AAC,�nmpensadon lnwrsnce carrier end Policy number am: timer.LLC3 Policy No<UL 1 97 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thb section need not mcompleted If tbe Permit is for one hundred dollars(5100) las.) 1 unify that in to performance of to work for which this permit is ism d,I shall not employ any Nown in any mmnerw as an become subject to IN Workeri Conpemation Lawa of Calif.mi..Dam Applicant , NOTICE TO APPLICANT.If.after making this Ceniricate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you most ,JO forthwith comply with such provisions or th permit shall W counted naval 'z H CONSTRUCTION LENDING AGENCY (-r I hereby arrarm tar them iso comtractinn kndingsgemy for Me"forms.of p:> Me work fur which this permit Is iamd(Sec.3097.Civ.C.) U O LeadersNarnc = z Lcnder's Addrue U 0 1 cenily to I have read this application and sum that to above infomniun la Iy I correct.1 agree to comply with all city and county ordinances and sum laws misting to �U Wilding convection,and hereby mahorrae 9pmsentative of this city to enter upon to r 6Wi above mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmlea the City of Cupertino against vF,t N liehilidmpall menu,com andexpe which may in any my acerae against said City U^ APPLICA 0uen NDBthegnnli of HAL NON-POINT Issued by: Date SOU y1_02 Re-roofs Signaturcof ApplicanUCan actor a>C HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Me applicant or rut=building Occupant atom or handle hasrdous humorist as dcflned by Ilse Cupertino Municipal Code,Chapter 9.12.and the Health and Safety IMM.d., e.Section 25532( All roofs shall be inspected prior to any roofing material being installed. ❑Ye No Will to applicant or mare building mcupam use equipment or devi ca which If a roof is installed without first obtaining an inspection,I agree to remove h hanrdnm air co mmanIS a dclincd by do Bay Area Air Quality Management all new materials for inspection. ole'? ❑Ye ]Nu I have mad to h4amous materials requirements under Choporb.95 ditto Califor. a N Health t Safcl Ode,Secdom 255(1;5533 aI25534.1undcmmrd Madam Wilding '�� y5( O es not cwt ave a ten my roe hility 1p today IW ox cent of to w LLL���aaa...www en nmLAI n ', aLp ar./ Signature of Applicant Date e All roof coverings to be Class "B"or better Owner or euthmacd agcnl D r 03o �o /� 1 (4 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEfI;TINO APN# 3 5(, 2 O D O6 1 Date: Building Address: Owner's Name• Phone#„ 3 Contractor:J License#: Contact: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech Job Description: LLc at J Residential /Commercial Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: .59 © 0 1] Occupancy Group: o . Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOTLER4 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 BMITIGATC Comm. Housing Mit. Fee BUILDING Z�2i13 lof3 � / � / CITY OF CUPERTINO ° PERMIT APPLICATION FORM CUPEI,TINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTME Ins cction 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 Pian 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm 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 Fumace> 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 2 of 3 S,r � CITY OF CUPERTINOITY OF PERMIT APPLICATION FORM CUPEIZ;TINO Quantity Fee ID Fee Description Fee Group 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Pian BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3