04070031 (2)CITY OF CUPERTINO
CONTRA TSR iNFOUMATIU
.. .:., .
BUILDING' DIV 3sloN -PERMIT,-
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BDILDwc ADDRESS: -
n4-�l PRITNE TRETE TA
ATLAS HEATING
PERMIT N90407003I
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY O. CONTROL NO.
4
ARCHIECf/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEGH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9 (commencing
Job Description
Op �y
I hereby affirm that i am licensed under provisions of
with $Ceti. 7 o Division 3 of the Busineea Orld Pr asmn9 ode a IICCnY 19
imm�forc t ✓/ & l
ss \itr(fr�
ADD A /C �.
License Gly° Lie.«_�
J(/�
Deu Cantmclor
Al ITECTS DECLARA 10
a
1 unticra pia all W cud as puhli recoNs
9
0 COQ
Licensed Pmf onal i
OWNER -BUILDER DECLARATION
I hereby affirm 'hot 1 am exempt room the Contractor's License Law for the
®O ((•IgO►�
following mason. (Section M31.5, Busiass and Professions Code: Any city or county
which requires a permit to c.marect, ebar.,impown, demolan, or repair any structure
.._
paler W Ila nateme., also mquints Iho appllcanl toaster remoter file a siland somereCnl
Sq. Ft. Floor Area
Valuation
thmhc ialicenud Purmanue the provisions a( the Commerce. License Law (Chapter 9
ith 700o) the Busine o ns
basison 3 of
Pn.
ch"itn
u Any itumn
I Nat he t exempt thcmfrom and t¢ boats far Ne alleged exemption. Any viole0on of
met be is exam de, m pl
31A&N_1 ihber00
Occupancy Type
Section 7031.5by any applicanrforapermilsubjecu the eppl¢enuo acivil Penaltyef
nor more Nan five hundred dollars (S500).
❑ L as owner of the property, or my employes with wages as their sole compensation.
Required Inspections
will do the work end the swctum is not intended m.ffemd (..seta (Sec.7044, Business
and Professions Cade: The Connector's License Law does not apply to an owner of
poem try who builds orimproves thereon, andwho doessuchworkhimself orthrough his
own wployeu, provided thatauch improvement are nalintnded aro@rW fmaak. if,
improvement is sold within ora yeti of
for me owes
builder Ne building
Improv
builder will have the burden .f proving mm he did not Wild or improve for purpose of
a
sale.).
El 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Commutor's Li.
cense taw does not apply to an owner of property who builds or improves Ihemon, and
.
who contracts for such projects with ac.ntracmr(s) licensed pursuant to des, Contactor
License Law.
i] 1 am exempt under Sec. , B & P C for this rca9on
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain eCcnificete of Cement to self -insure for W.rker'sC.mp.n-
sation, as provided for by Section 37M of the labor Code, fm the performance of 'be
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance. as required by Section
work forwhich Nig permit iaissued.
Labor Code, Insurance
Imunnce Polity
c orathe
My WorkeN Compenseton c or and
My .rk
C P.I��kyy{{,,((�O V JI'/ice—lel
'
C RTI^ WORKERS'
COMMEND( TI I SF'RO
COMPENSATI NI SURANCE
(This section need not becomplemd Babe l ornil is for one hundred doihrs (SIM)
'
I cenRy the, in the performance of the work for which this permit is Wood, l shall not
employ any person in any mannersn u to become subject In the Workcre' Compensadon
Laws of California. Dat
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject m the Worker's C.mpen anion previsions oldie Lahnr Code, you must
forthwith comply with such provisions or this remail shall be dcemed mv.kcd.
ON LENDING AGENCY
CONSTRUCTION
is a construction lending agency for the performance of
1 herchy.Rrm Net mere is aed
(Se.0
' the work fur which cels permit Is issued (Sec. 3097. Civ. CJ
Lender's Name
-
Lender's Address
i 1 certify met I have mad this application end tote mat me above inforn im. is
' comact 1 agree to comply with all city and county ordinances and sure have aching u
building construction, and hereby authom, rep esenulivce of oris city to enter upon the
abeve.mendoned property for inspection purposes.
d (Wc) agree to save, indemnity and kap harmless the City or Cupertino against
j liabilitiesjudgment,c.st and expenses which may in any way accmc against said City
in consequence of the granting of this permit.
' APPLICANT ERS NDS AND W OMPLY WITH A N POINT
Issued by: at
SOURCER U ATI S.
Re -roofs
Type of Roof
4
S' nature. A onwclor al.
HAZARDOUS MATERIALS DISCLOSURE
Will due applicant or future building Occupant stem or handle havardous material
as defined by the Cupendne Municipal Code. Chapter 9.12, and the Health and Safety
.de. Section 25532(a)7
All roofs shall be inspected prior to any roofing material eing in/edo❑Ym
o'win
If a roof is installed without first obtaining an inspection, I agree
tee applicant. alum building occupant use equipment or devices which
it haaardnaa sit cont. hent fined by she Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes v
Ihamreadthehara usmamrialsmquimmenuunarChepor6.95orme Califon
nia Hcalm&SafctyCou, cdomM505,25533md2553a.1undcmwdthairme Wilding
Jose not cv Iy ham nand. resp.nsihility I. nobly me rccupan of me
m imme wichrp IW melpdontiesu ritccnfleatej y
Signature of Applicant Date
`.
All roof coverings to be Class "B" or better
Tea tat xedag ale
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
ba
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Y
C�
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T'
7- ,
Date
�4pr
q k�'
hats
CITY OF
CUPEII,TINO
APN #
0
zl
CITY OF CUPERTINO
FURNACE /AC b if o
PERMIT APPLICATION FORM
if
AnnWMnhle
Faa Tn
- -
BENERGY
Date:
rcc �ruu
BUILIDNG
BREMFURN
Buildin Address:
MECHANICAL
Ownis
( e:Phone
#-
BREMACOVER
A/C Unit > 10,000 cfm
o a5a -
Con c or:Licen1
137
Contat:
Phone#: p
Z O3�
Applicant/Contractor:
ELECTRICAL
Building Permit Info:
Bldg lett Plumb ech
Job Description:
Residential:
� � _
Seismic Fee Res
3 Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation:
Elec Permit Issuance
a 5 Ie 3
Type of Construction:
Occupancy Group:
if
AnnWMnhle
Faa Tn
- -
BENERGY
.."..
Ener
rcc �ruu
BUILIDNG
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIRHAN
A/C Units <= 10, 000 cfm
MECHANICAL
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILIDNG
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMTI FEE
—Plumbing Permit Issue
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG