04030032 ' ' "
BUILDING DIVISION PERMITM1CONTRACTOR INFORMAT,ION5�A;
BUILDING ADDRESS: ATLAS HEATING PERMIT ND04030032
W NER'S NAME: PERMITI55UE DATE
DO
ONE:
SANITARY O. CONTROL N0,
ARCHITELT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Loo LICENSED CONTRACTOR'S DECLARATION Job Description
ZC 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing
<U with Section )of DiviYon7of NC Buri uW Profusinnt cade.mi licerac is
^_tom
is fail deme" 6 �_ REPLACE FURNACE & A/C �'��, L�®
z fa- Dole
ua Lk.
Dam Tun r mY plans dull M1e used mhlic mcmdis
�yU
MAR 0 8 2004
;Qt; Licensed PmfcoitnBl
OWNER-BUILDER DECLARATION 1
I Mmreason.(Rte onn I I. exempt from d r Qaains Co License Law for Ik BUILDING
x 2 O following uiresa (Saito]onstr Business and Re,demolish.
em li Cade:Any city m county
j:00
$ which rcquins issuance.pcmit re aims dk,alter,,forsu h Per it t fi repair any Structimment
e nno
priares iused &ISO She thoi,incant for such U,,cic a Ladaukmem
H£s< thukislingwi pts on7"She).fDisiou 3.fc nue...dcofse w(Chap¢r9 Sq.Ft.Floor Area Valuation
d F$
(comm ea exampN Sttdoa]and Of hands f J of the eland coand on.Any vi latda)tar
Net k V eumpl therefrom and Ne buts for the allegrd excmpdm.Any violation of
Section 7071.5 by airy applicant for a permit subjects the sPplkant to a civil Wally a 3W?Y2'0jMgr00 Occupancy Type
not more Nan five hundred dollars($500). _
D I,u owocr of tW pmpwy.m my employcu with wage u Ncir sole compeuman,
will dolhework.aaux:Th ovoiawr's Li cdmaw dons Out apply So In Onamircsf Required Inspections
and ery.h.nd Cade:The Convenors Lirv"-Law dam Out apply lf an ower is q P
propertywhabusIdsored that eWreproandvena doe ssuchw«khimselfor through his
Own employes,provided that vememprm id w is are ml our o cd proffered for Sale.If,
however.the Wilding or improvement is said within o«year of completion,Ne owned
Wader will have Ne burden or proving that rte ata ter Wild in improve f«puryue of
sale.).
D 1,as owner of Ik property,am exclusively convecting with licensed contractors 1.
condenser the project(Sec.7014.Business and Profusions Code:)The Contractor's Li.
cone Law docs not apply b an owner of property who Wilds or improves Omreon.Md,
who controo for such projects with a conuanor(s)licensed pursuant M Ne Contractors
License law.
D l am exempt under See. ,B&P C for this moon
want Date
WORKERS COMPENSATION DECLARATION
1 hereby aRim under peuley of perjury ane of the following declarations:
1 haw and will maintain a CeNfiam of Consent to self-imum for WarkeM1Compen-
13700
hm,u provided f«by Satin 3]00 of the IaWr Code,far do perfarro—of the
rk for which this permit is issued.
I new Bud will maintain Wmtrr's Compenu0on Insurance,u required by Sado.
of the Labor code,fur Ne performance of Ne weak for which Nis permit is bound.
y Workers Compenution Insurance carrier and Policy number rt:a Polity Na.:
CERTIFICATE OF EXEMPIION) WORKERS'
COMPENSATIONI U E
rentsse mradmtkcompletedifIWpcmieuf«onehundreddollars($]W)
tr leu)
I anify that in Ne performance of the work for which Nis permit is issued,I shall nut
employ any pedi n in any manner set as,to become subject to rk Workers Compenudon
Lavn of Califomiu Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenifica a of Exemption,you Should
become subject w the Worker's CamPmisoll n provisions of the Tabu coda,you must
7, forthwith comply with such provision or this Permit shall be dccmed mvokcd.
Z O CONSTRUCTION LENDING AGENCY
I hereby arOm that there is a construction lending aaary for lW perfumana of
IZ 7 the work for which this permit is issued(Sec.3097,Civ.C,)
{p1 Unders Nam,
:D Lenders Addmes
U C) I anify that I haw mad Nis application and sum that tic above information u
U. P torten,l agree to comply with all city and county ordinances and soon laws relating to
0 U building convection,end hereby authorim repruentalivu of Nis city to enkr upon the
W abovomemioned property for inspection Purposes.
(,6. (We)agree to ow,indemnify and trop hamlest the City of Cupertino egaindr
h liabilities,judgments,cases and eapa"ses which may in any My...against send City
U Z his parrit.
APPL CANToUNDERof the m�ANDSding of IAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC R ATI N
Re-roofs
S as me Applic+nUConuaaor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me applicant or future building Occupant sloe,in handle barardous mammal
IDistim?&read by Ik Cupnino Municipal Code,Chapter 9.12,and tic Health and Safety
ode,Section 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
DyesWill Nc applicant or future building occupant ase equipment or dcviccs whichIf a roof is installed without first obtaining an inspection,I agree to remove
mit huaNtnd air codominants u&road by dse Bay Ams Air Quality Management all new materials for inspection.
❑Yes
1 have read tic haordousmamriaisnxommets underChapter 6.95 ordm Califor-
oorSfetyCada. n,duar 5 in) and25531.1 indao ry. Orionma not curtcndy hew a n6 Nor it u my responsibility m notify occupant 11 dmgaim uwYm at m rtoisaBanentr,eWOamarOca _ ! Signature of Applicant Dale
stet GIG yp'�� lfE� All roof coverings to be Class"B"or better
u a anted egcm/�� Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
OUPEkTINO
uildin De artment
JOB ADDRESS: �2 ( �;Z 1-Ly (C �, PERMIT# 6„
OWNER'S NAME: c SNA L EW) N6 PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating LLo
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
FURNACE /AC o 0 3 D- Z
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # -2 �a I Date:
`J 3 , n
Building Address:
a i 5 c0
Owner's Name: Phone#
70
Contractor: (I I License #:
Contact: ` P Tonne #; t
I
Applicant/Contractor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: p
Residential: K4 R r--,Oua C Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: V:Iluation:
L O C7c7
• Type of Construction: Occupancy Group:
if
A li ab Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit > 10,000 cl'm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILIDNG
EPERMITFEE Elec Permit IssuanceELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit lssk;e PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
# L/
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