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CITY OFCUPERTINO
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' CUN'fRA�TUIi I1 tUItM�A,, It?N
BUILDING DIVISION PER
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BUIILDING ADDRESS:
ATLAS HEATING
PERMIT '003060075
OWNER'S NAME:
155 SAN LAZARO AVE
PRU Tf LS"NT10 /2003
(408)739-0516
SANITARY NO,, CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lb Description
o
n Ihems under prevision of Chapter 9 (commencing
I lu mby srrbm that I g ed
MthSectrm7aa)ar Dlvision3orda EusineuaMP(�rIo (muse CM.mdan Cliental,
and cr 26
SO
Lcfenl�aree
uc g T
REPLACE FURNACE & ADD A/C ALE.®
Dam Canrrenar
ARCXITE W
shl LTS DECLARATION
i uNmem, my pin al used as public meads
JUN 2 4 2003
Licensed Prof cssiunaI
OWNER - BUILDER DECLARATION
I hereby affirm shad I am exempt from the ComtanoYs License Law for tite
' 1
BUILDING
following ressm. (Section 7031.5. Business and Profession Cade: My city or county
C
which mquires a permit to maumt, eMn heron. dcmoihh, or repair my structure
prior an its issuance, also oursha dte ipplinnl rorsueh permit an file a signed autemmt
the he is licensed pursuant to tite provision of IM Co...,. U.. Law (Chapter 9
Sq. Ft. Floor Area
$�Ogtion
(commencing Mth Smion7000) of Division 3 terthe Bainm gnd Profmiou Cade) w
that ha u escort therefrom and the bash for tee alleged eamptim. Any violglm of
3 42N80ii5er 0 0
Occupancy Type
Section 7031.5 by any applicant For a permit subjects the applicant to a civil penalty of
set mom than Bw hundred dolhn (5300).
❑ 1. as mvnr of the property, or my employees with wiles as Nei role compemadn,
—
dons
Will do the work, and the green. h and intended or offered for am(Sm. 7044, B.31 a
and Profession Cade: The Comsemrt Uane law ones can apply be an owner of
303 3 — ROUGH L
s thean, mdwM doessuch work himaelrtnihomgh his
property who builds orimprew rc
own employees. innovated that such improwmenu am not intended coffered (male lr,
304 — ROUGH ELECTRICAL
however, the building or improvement is sold Mara on year ormmpletion, the owns r.
Mllaer MB ban des lurden of proving dm M aid set ado or Improve fa pecpom of
505 — FINAL ELECTRICAL
ale')'
507 - FINAL PLUMBING
wruvn licensed
ei wctdeeproa%04
comlepX(P71e �m nd osc
508 — FINAL MECHANICAL
n
o > acuses L
ante law Ones not apply to an owner of Ptolemy who Wilds or Improve thereon, and
who contracts for such projects with a com mur(a) licensed remains n the Contracture.
'
Liana law.
❑ I are exempt under See. . B & P C rte Ws reason
Owner Date
WORKERS COMPENSATION DEC"RATION
1 hereby aRirm under penalty, of perjury one of tba following declaagers:
1 bave end MII mrinWn •CWfswm of Coro.. w olf -laure fa WoftesCompen-
sadon, a provided for by Lima 3700 of the labor Code, for the peAormeae of the
wpk for which this permit is imueO.
I ban W MII maintain Workrls Complemented Iamarm. a required by Section
]O0 of the Labor Code. for the pullomana of the wort for which this permit is issued.
yWO a .sere oImum gaMa and Policy mmd:r art:
Carrier. I,4 No.: tj LF C 43-5,221 ,
CERTIF CATS OF EXEMPTION FROM WORKERS'
R
COMPENSATION INSURANCE
(Ibis smim need not be completed if tint permit is forme Imumd dellua (g 100)
or leas.)
I clnify that in the pu mmace Of the work for which this permit is issued. I .hell not
employ my resew in my manner an as to aSome subject to ft Workem'Compenation
Laws of Califomia. Date
Applicant
NGnCE TO APPLICANT. If, gr m making this Cenifecase of Exemption, you should
become subject m the Worker's Compensation provisions or the Letter Code, you mug
-
forthwith comply with well provision or this Permit Nall W domed mwked.
CONSTRUCTION LENDING AGENCY
1 hereby air,. that them is a construction lending agency for the performance of
the work fm which this permit h issued (Sec. 3097. Civ. C.)
Lender's Nune
Lender a Address
I emify Out I haw read this application and sou diet the awn information Is
'
comet. I agree to comply with all city and county ordinance and some law muting to
Wilding construction, ad hereby authodm mrmsemOves of this city to enter upon the
above- mentioned property for inspection pugwses
on, Indemnify and keep hamlet (he City or Cupertino against
(We) agree in m
liabilities, Judgments, emu and expenses which may In my my acc= against aid City
in mmuquence or the flooding of this Permit ,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N P TNT
Issued by: D
SOURCE REGULATION
Re -roofs
Type of Roof
Signmure of AreplicmuCOUNI.r Date
HAZARDOU MATERIALS DISCLOSURE
Will dim applicant or future building occupant gore or handle haudaus mamgg
as &flncd by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
ode. es 2ss32(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yea
0
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding moment ac equipment or device, which
II hazganm air comominanu a defined by the Bay Area Air Quality Management
all new materials for inspection.
isdrim7
❑Yes
1 have rcM the hmanbwa materials requirements under Chapter 6.95 of the Califon
ilia Health& Safety CcEc,Scction 25505.23533 md25534.1 understand that if the Wilding
teas nut mocully haw a tenmL diet It h my responsibility In ratify dte uxupant of the
requimmcn kh elpdar an . c or.cenincatcoroccuoncy .
Signature of Applicant Date
6 10
All roof coverings to be Class "B" or better
.war or amMdua set Da
C,
i
CUPERTINO
CITY OF CUPERTINO
FURNACE /AC
PERMIT APPLICATION FORM
�
03 vt, % S
APN # .3 `f Z - G Ff ' 0 3
Date:
Building Address:
Div
D
BUILDING
aa6
BREMFURN
Owner's Name: ,n
f/
Phone #:
T
Contra or: Phone:
- �/o� os/ �
License #:
q6,
4zeKdw e .� _
MECHANICAL
Contact: Phone:
Cupertino Business License #:
Building Permit Info:
MECHANICAL
Bldg ❑ Elect Plumb�gp
Mech
J b Descripti n:
-
�r c 3 >or -
BSEISMICRE
Residential Commercial ❑
BUILDING
For R idential I401lations:
"d ❑
EPERMITFEE
Attic 1" floor ,gl 2 floor
ELECTRICAL
Adhere to min set back re uirement
MPERMITFEE
For Commercial Installations:
MECHANICAL
Replacement same weight ❑ Additional weight (structural calcs) ❑
PPERMTTFEE
Structural Calculations required for new installation ❑
PLUMBING
New installation Planning Approval Required ❑
BPERMFEE
Cost of Project: Type of Construction:
Occupancy group:
S o • o-D
BPLANCHK
Strapped ❑ On Platform ❑ Bonded ❑
Sq.Ft. Floor Area:
❑ A-"
BUSLIC
New Location Replacement
BUILDING
Qty. if
Annl i cahle.
Fee M
Fee Descrintion
Fee Grout)
BENERGY
Energy
BUILDING
/
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
I
BREMAIRHAN
A/C Units <= 10, 000 cfrti
MECHANICAL
I
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
/
MPERMITFEE
Mech Permit Issuance
MECHANICAL
/
PPERMTTFEE
Plumbing Permit Issue'
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License 44
BUILDING