03080154' ITY OF CUPEW11NOBUILDING
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DIVISION PERMIT
GTOR-INFORMATIONiP
MATIONLDING
ADDRESS:
ATLAS HEATING
PERMITND03080154
NER'S NAME:
i
155 SAN LAZARO AVE
PERMIT ISSUE DAM
NE:
(408)739-0516CHITECT/ENGINEER:
SANITARY (J CONTR04 NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p LICENSED CONTRACTOR'S DECLARATION
Job Description
I Mreby.ffrm that I em licensed under provisions of Chapter 9 (c ,nowneing
with Socuon 7") of OM.lon 3 of um Box. and Profoxiuns Code. and my license la
in full farce and c(fm S �,
�'�
REPLACE FURNACE &ADD ASC
z License Cl Liao.
Dam Cumracmr_
ARCHITECTS DECLARATION I/).wr
1 underuenJ my prom shaft be used a Puhlic mcorN
//�
"a �i a
CCS
Licensed Professional
OWNER BUILDER DECLARATION N
m
f 1 affirm n 1 oro exempt from the Cnnlrac,Co License Law for the
(s
O mason, (Scion7031.3,Businessand Profdeioli Code:
mase , o
.v0
which myvires a permit m construct, alcor. improve, any nmctvze
which
C
in slits cenaMpursor,toshe lheaiions rI h cruilt fi e.,i,
Law(Nlemenl
Sq. Ft. Floor Area
BS Valuators
< thatWor
offs, Conuslm111aiemsc
Calc)
y„ {.
(commenctt ng withSemion7")ofDiviomo(IMCanuulor'snisxnusemorCapler9
or
$ (cat exempth Section of Division r of and Poureon,
p.
atl
the al eged axe
Any
Net he is exempt therefrom and the hose for the alleged ezemption. Any violation .f
he is
-__-_ APN Number _ .___
'
_. Occupancy Type_
Section 703 L5 by any applicant for a permit objects she applicant -to. a civ. penahy of
not more than five hundred dollars (5500).
❑ I, nawnnofthe property, army employes with wagesas thehmlecompeme,lon,
301 - ROUGH R UtVI�Id`� coons
will do Newark. and thesnucture is not intended ar offered far .1.(Sec. 70". Bushes
Cattle: The C.nctura License Law docs, not apply to an owner of
and Prifeseians Cadw
property who bunds.r7mpron, mamon.md who doesmch work himself., through his
303 - ROUGH M CHANI AL
own employees, provided that such impronmenu art not intended or.ffered!.sale. If,
304 — ROUGH ELECTRICAL
homwr, the building or improvement is sold within one year of completion, the owner.
builder will bees tM burden or proving that be dm m, Wild or improve for puryme of
505 — FINAL ELECTRICAL
507 - FINAL PLUMBING
1, as owner of the property, am exclusively contracting with licensed contractors to
colmuucl the pmjcct (Sec. 7W, Business and Plofeni.ns Code:) The Contractor's Lit
-
508 — FINAL MECHANICAL
cense Law does not apply in an Owner of property who W Ilds or improves themon, and
..
who contracts for such pmjecu with a contractor(s) licensed pursuant o the Convectors
License law.
I man exempt under Sec. . B h P C for this mason
net Data
._ - ... .
WORKER'S COMPENSATION DECLARATION
- -
IherebyaRlmunderpenaltyof mijury am of the following dederathrit:_-
1 Mee and will maintain a Cer irmate ofCmssent to sel6insure fm WorkeraCmnpen-
a0On, u provided for by Section 3700 of the labor Cade, for the Performance of The
'
— work for which this permit is issued.
hive and will maintain Workers Compensation hummer. n required by Section
700 of the Labor Codl for the pnfmmance of the work for which this parmil is issued.
M W. amp��J�gS=tion�1 ram. nrtiv end Policybournal afrrer�: Z21b
CemerA/filL 1.AN'W1. • Policy...W�a+`t'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
maisseclion need not Mcompleted !film Permit is for one hundred dollus ($IUIn
or los.)
I certify Nn in the performance of the work for which Nis Permit is issued. l shell nut
employ any pmmn in any manner sat n m became subject m the WOrkefs' ComPe 3AIum
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Ccnifcam of Exemption. you should
become subject to the Worker's Compensation provisions of tbe labor Code, you mum
forthwith comply wish such Pmvisiry er This Pc,mi. hall be deemed mvokcd.
CONSTRUCTION LENDING AGENCY
I hereby af0rm that there la a ConswcOnn lending stormy lnnhe performance of
the work for which this Permit Is issued (Sec. 3W7, Civ. C.)
Q landue. Name
L=rders Address
z
I cenify that 1 have reed this application and sum That the above information is
couch. I agree m comply with all city and county ordinances and smm laws misting to
building constriction, and hereby authorize mpreaenl.rives.( this City to enter upon me
for inspection
abon-mentioned propany purposes.
(We) agree to an, indemnify antl keep harmless the City of Cupertino &gains,
liabllitiu,judgmenu,cosu and expenses which may in any way accrue against said City
7 in consequence of the granting Of this permit.
APPLICANT UNDER 1 WILL C PLY WITH ALLPQlrrr
Issued by: Date
SOURCE REGULATI
i^�
Re -roofs
Type Roof
Signaurt of ApPlicanVCoDam
HAZARDOUS MATERIALS DISCLOSURE
of
WIII the applicant ser (umm buildinghandle h imateriel
k, Clnomm
Health
OSed by the Cupertino Municipal Cock, C 9.12, and the Health and Safety
. Section 25532(a)7
All roofs shall be inspected to any roofing material being installed.
❑Yea ash!•
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or dcviw which
havardois oi, commit nanu u defined by the Bay Arta Air Quality Mmatcmcm
all new materials for inspection.
❑YesI
lOwner
has real use hvan(nusmaterials requirements unaerCMPter 6.95 oldie C.lifor.
ealth" SafcryCoact Scapi. 25505.25537 a11d2553d. I mgkumnd out' ore Wilding
not cunamly hap • mar.m. the it 4 my mspons,"I ty m..dfy tis: pentfate
mepd.rm ampe.ncenirmate.r =
Signature of Applicant Date
A11 roof coverings to be Class "B" or better
nrmm..<a am m
D
i
1
CITY OF CUPERTINO 63
FURNACE/AC /
PERMIT APPLICATION FORM
APN # �- O
Date: ;1,0-3
Building Address: l/0 73C -3p--
BUILDING
Owner's Nam &.¢�
Phone #:
3 z 7
'/�¢wL�C�,t�
ContraE/ Phone:,po8
License #:s Z739�S/( 6
��
Contact: Phone:
Cupeno cense #:�2�
Building Permit'Info:
BREMAHMAN
Bldg ❑ Elect"K Plumb ❑ _
Mech
Job Description:
BREMRECEPT
6 Q l�fb{
ELECTRICAL
Residential Commercial ❑
BSEISMICRE
For RggA�identialfellation:
LJ ❑
BUILDING
Attic ls` floorrU 2nd floor
EPERMITFEE
Adhere to min set back requirement ❑
ELECTRICAL
For Commercial Installations:
MPERMITFEE
Replacement same weight ❑ Additional weight (structural calcs) ❑
MECHANICAL
Structural Calculations required for new installation ❑
PPERMITFEE
New installation Planning Approval Required El
PLUMBING
Cost of ProjeStcaaa o Type of Construction:
Occupancy group:
Strapped Llff On Platform L1 Bonded El
Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
BPLANCHK
Qty. if
Annlicahle
Fee M
Fee Descrintion
Fee GrouD
/
BENERGY
Energy
BUILDING
BREMFURN
Relocation of Furnace
MECHANICAL
BREMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAHMAN
A/C Units <= 10, 000 cfm
MECHANICAL
BREMRECEPT
Rec tl, Switch & Outlets
ELECTRICAL
BSEISMICRE
Seismic Fee Res
BUILDING
/
EPERMITFEE
Elec Permit Issuance
ELECTRICAL
J
MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMITFEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING
�5�` 54L