00110093 CITY
oNcuPV:H rNNo
I PERMIT CONTRACTOR INFORMATION:
BUILDING ADDR&SS: PERM TT NO.
854 LILY AV ATLAS HEATING 001.10093
OWNER'S NAME: APPLICATION SUIT DATE
"WANG 155 SAN L.AZARO AVE 1.1117/2000
PHONE: (408) 739-0516 SANITARY NO. CONTROL NO.
Ox% ARCIIITE=NGINEER: BUILDING PERMIT INFO
0 L) BLEX5 ELECT PLUMB MECH
U CI CI I_I f=1
LICENSED CONTRACTOR'S DECLARATION
z E v ,IIx m e Job Description
Scrota
a-ny af6nn dna I ren ofthefdsirm,pen . of Cbfot Y ad 'mg
°y{.w . . f1cllnn701XOo1'Dlvixiulm3nfthcliusinmsundll%rnroax,anv1 la,andh,tyhrcensa ADD A/C
yS i,in full forcemr., a rel ') Pctf n
z N 1' .C Com_ .it.tr 4.��,,,(,f?%� LLLIIIIYY'l/�_
Contractor
Ans shall be used
DECLARATION
g I understand my plans shall be used az public raoNs
El /p,O Licensed Profe,sional
OWNER BUILDER DECLARATION
a of= I hereby:)lion that I am exempt from me Contractor's License Law for the
Fy�
foloin,reason.IS nit 7011511 : d Prole,,i xcode'.AY city or e, it, a.
'pFO sheen re,fire,aI II tom,1. e p lis t,i repairanys ante
to I'm),to it, 'e it hapte'dw alrlw Fo oh womi,to Flee , greed nr Wnem
c. roar he i.licensed pursuant ameIF —ons„f toC...memr',Liver,Law(Chapter 9 Sq. Ft. Floor Area Ilmteo
(commencing with Section 7(XX)1 rel Division 3 of the lhrvmras and P.Ic,sioa,Code) !/
or that he is exempt therefnm and the basis for the allege!exemption.Any violation
of Section 7031.5 by any applicant for a at subjects the applicant to a civil penalty
,if nm mote man live hundred delta.($500). APN Number Occupancy Type
❑L as owner of property.or my employee,with wagesax their.vote compea,ation, 35903039. 00
w d do the k 1 the structure t intended or ottered For (See.71M4, -
!In r _ dP f ('011c: fn C , :I J r pllytoa. Required fnspections-
fp p ny WI n lit ' , I I I k l ,.vee 303 '— ROUGH MECHf-1N I CAL
urvlhamyh la,own n npl or, r,mod that suchnano, a m, rel rte deed,t
offend lot sale.11.however,the building or improvement In old within one yenof 304 — ROUGH ELECTRICAL
completion.Inc owner-buiMer will lime the burden of proving that he did not build ar
improve fP.,),ofsafel. 505 — FINAL ELECTRICAL
01.a,owner of the pro,cri.am exclusively contracting with reem,ed eonnowbas to 508 — FINAL MECHANICAL
contact the pmjecl(Sec.7011.Business and Pmfessionx Calc:)The Contractor's
[Active Law Jrps not apply em an onmer of property who builds or improves thereon,
and who enntmeB for such pmjecl,with a cornmemrfal licensed pursuant m the
Cmatraemr'x Liecn.w Law,
Cl 1 ant exempt nwncr Sec. .If&PC fr this rehno..
(),act Datc
WORKER'S COMPENSATION FAKI.ARA'I'ION _
I hereby affirm under penally of perjury one of the follom i,declarations:
❑ 1 have and will next main a CeniBcate of Consent to self-insure for Workds
Compensation, as provided lin by Section 3700 of the Labor Code, for the
performance of Me work far which Ihis permit is i.xaled.
131 have and will maintain W..ler',Compemation In.aurnncc,Lax required by Section
37110 al the].shot Code,No Inc Iart'annmme of the w+nk Ior which'his permit is
wed./M1yy WO1 tier',Ciao,c'nwattiion Insomuce lam and/1I'nfllii, amalher am /
.0 erg 4111k f—. 1 Policy No
L'R I C, L PIL"xHv ION ROn1 W(yRKERS'
COMPENSATION INSURANCE
I His section need not he completed if the penton is for one hundred dollars
CS 100)m leve)
1 cenify that In du Parfnmmnee of the work Ro which this permit i,issued.I
shall not elndoy any Ian to my none if'r so Ia nwmm
ce"after the Wnrkerx'
Caoln, aeaion Laws of Cidhfomia.Uate
Appueaal
NUI ICI!TO APPLICANT:If after making this Cenilicam or Exemption,you should
ha,mc sun ect In the Worker.,Competnalioa...wist.....of tic Labor Cotte,you must
O forthwith comply with such provi.xions or this permit shill b:deemed revoked.
Z
[^�I rim. CONS'em is.coNLction AGENCr,aY
' 1 hereby affirm that them is m construction(Set. 097.lending agency Studio pNommance
.file wok for which tris,prom is isnuN(Secs 91x)7,Civ.Cd
S Q Lender'.Name
lender's AdJmuss
U 1 certify that I have rend Iniv appliiCalinn and,tum that the anove moan,ation is '
W (� omfecl.l agree m m.. 1,wilt all city and County onfnaoce,turd ntutu law,mating
O U to building ronwmmioa.and hemov mumenr4 reprewnmtives A Ihis city In enter uqm
} iii the nMneancmioned property far hnpcoam PUBusc. _
E., a. (We)agree to acv.interfamily and keep hamdet s the City of Cupertino again,,
rp liabilitie,judgments.co,u and e.pert which may in any way accrue against said
V 7 City in consequence of t gmming of lhi"a"ca 1. I _1
APPLICANT 1) ANDS AND WILL COMPLY WITH ALLNO -POI Issued by: Date ` `'
S( BCF. T 'S, ff 11
tiig�Itl r , naalm - D� Re-roofs
Ic IIA'lAItDUUS MATERIALS I)ISCLOSIJRII
Will ea 0cam or future building occupant More or handle hm,,,nouv nuarrial 'Type of Roof .
u,dctifec n In Cupertino Municipm Coda.Chaprer 9.12.and the Health sad Safely
Code,Seen, ' 532m)'I
0 yC, 0N - All roofs shall be inspected prior to any roofing material being installed.
Will the applicant nr future building twcupaat use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit h:nudous air contanunams as Jehned by the Bay Area Air Quality Management
• Distmn9 all new materials for inspection. Applicant understands and will comply with
El yes, ❑No all non-point source regulations.
I hove read 0m ha,uol mmenal,mmtphimmchhf Lauder Clutplcr 6.95 of de
Cah arnia Mello&SldBly Code•Sec1i n,25505,25533 amt 25534.1 m,dmnmad Ihal
:tit Is to docs mol nnrcnllY have ¢nanh thmili,mytcgamaihility to notlly the
Occupant f e requircn,cnn which msi lwmel prior m issuance o t Cert'nam al _
(kcupun it ? `me
(/ O Signature of Applicant Date
a ihmucd mgenl Date All roof coverings to be Class"B”or better
OFFICE