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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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CONTxitCTOR,TNF'IiMA�I'I�;
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But ADDRESS:
ATLAS HEATING
PuRAmT N'05020101
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANRARY NO. CONTROL NO.
ARCHITECr/ENGINEER:
^ BUILDING PERMIT INFO
QPLUMB MOECH
LICENSED CONTRACTOR'S DECLARATION
I Money affirm That I am licensed under prove om of Chapter 9 (commencing
wiw Salion?0M)of0 vision3ofthe Busisu OWProfeWou Com,andmylicenceis
m toll cores ma sff -Lic
Da¢N0 A- b^s's O
Job Deacripti v
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REPLACE FURNACE
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ARCHIIARCHITECTST1'S DECLARATION N
I be
understand my phua "I used As public rteorda
Licensed Pmfcxs(onal
OWNER -BUILDER DECLARATION
I hereby oRrm That I am exempt from the Canhacmh License law far the
fallmving moon. (Section 703 1.3, Buxhlexs and Pofadom Cade: My city art county
all,moon.
which a permit to consumer. alwr, improve, demolish, Or repair my wucture
��
prior to ILL Issuance, also mquiree the applicant for such permit to file a signed Wlemcnl
that Is licensed pursuant to flue provisions of the Connector's Uccnu Law(Chaptor9
Sq. Ft. Floor Area
" Valuation
(commencing with Section70M) of Division 3 of Ne Business and Prefectures Code) or
that he is eumpt thertftmn and the basis for be alleged exemption. My vloladm of
3 ]�'B4iIAlHfibe4 0
Occupancy
p y Type
Sweden 7031.5 by any applicant for a permit subject, the applicant to a civil penalty of
am mere than Ove hundred dollars (S3M).
❑ I, As owner of the propany, or my employees with wages As Neto sets compewtion.
Required Inspections
will da the work. and Ne.momm cams intended seroffired forsale(sew. 7014, Business
and Pedessioua Cade: The Canmemes License Law does rot apply to an owner of
.
propeny who builds or im prove daemon. and who doessuch work himset f ur through his
We employees, provided dwasuch improvement, art not mormalra oro0emd forale.If.
however, the building or Improvement Is sold within aro year of completion. the owner.
builder will have that burden of proving that M did nm build or Improve for purpose of
sale).
❑ 1, as owner of the property m exclusively comm ing with licensed conuacmrs w
consumer the, pro)en (Sec 7011, Business and Pmfe d.. Code:) The Contractes U.
ante: law dura not apply to an owner of property who builds or Improve ounces, and,
who concoct, for such projccu with a canuacter(s) licensed pursuant to Ne Comrmtor's
Licenm law.
❑ I am exempt under Sec ,B Ac P C far this mason
owner Data
WORKER'S COMPENSATION DECLARATION
1 Mrtby affirm under penalty of perjury arc of the following declarations:
IhswandwillurnimainaCenifiauaf C. Ment to self-imure far Wallace. Camper.
-
adoas provided! by Salion 37M of the Labor Cade, far da perfamance of the
imn,
Asst (or which this permit is ed.
011 have and will maintain Worker's Compensation Iawrance, As required by Section
3700ofthe Ua Code,fordaepehfemasueofsitewokforwhich Nupemuisissued.
My Work ompemauon GInwaym�e a rand Policy number m'
Cartier. Alz / YM /�( Polity No.: 1766 Zf 62
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section sued not be campIcsed title permit Is farrow hundred dollars (SIM)
or Ica.)
I amly that In the performance of oe were: for which this Permit I, issued. I shall nm
employ any person In my manner an as a become subject to the Workeri Compensation
Laws of Caiif(min Date
Applicant
NOTICE TO APPLICANT: If. site, meting ois Ondricare of Exemption, you should
became subject M the Webers Compmmtlon proviximu of the hone Code you must
forthwith comely with such provisiaru or this Permit Nall W domed awaked.
CONSTRUCTION LENDING AGENCY
1 Mmby afRm IMI there is a com0uction lending agency for the Performance of
to work for which this permit Is is ad (Sec. 3097, Civ. C.)
Lmdeh Name
Lender's Address,
1 really that 1 have read This un and mm this above information mtion h
corms I rt comply with all why and roomy And
city and c and cot, laws relating
once
ntatwue,
building convection, and hereby wNonu representatives of this city u smart upon the
e
shove mentioned for Inspection
-sonroperty lampuc
(We) agree m arc, indemnify and hick hay the City of Cogent against
Ilabllidas.judgmenu,comand expenses which may In my way accrue Against said City
in m
thI is
'
i
I O
Acomegnena of permit
CTA g of
AP ANT UNDERSTAN AND WILL COMPLY WITH/' L NO POINT
Z A / •
Issued by: Date / v
OU CA� g�(JIII.ATIONs.
Re -roofs
= J
Signature of Applia11C mor Date
N Ro,= MATERIALS DISCLOSURE
Type of Roof '
WIII six art fMuni building uare sur handle mammal
,
tic Cupenina Municipal Code, Chaptor 9.11, cosi the HeaIN cosi Safely
as de. w Cuart e, Chapter Health
Setl io
Code, section 353334)?
All roofs shall be inspected to any roofing material being installed.
❑Yen 0 N
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding aecupant use equipment as dcviaa which
mit harwilm air cenmmivanu As defined by oe Bay Arca Air Quality Management
all new materials for inspection.
Dixnin?
❑Yes ONO
I have mad the hasartiousmaterals requirement, underCMpmr 6.95of the Califon
ria Haiti & SafmyCode,Swdms35505.25533 and25534.1 undomam Naifthe building
dos no ntly ha mnsa it miIt�v wood the occup al of the
m
regoi come altoiatuyaanceorreapomiu=.a Oc
!.'� (D/uca�
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner or aaoanvca agent
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
M3 -Q6 u ri—Free- Lr)
PERMIT #
06Ox0/ 0
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR: a --f- at S -7-r1110 12
FAX #
I am not using any subcontractors:yya (:�` /6/d FJ
Sig a Date
Please check applicable subcontractors and coml5leto the following information:
60
SUBCONTRACTOR
BUSI E S NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
11
Owner/ Contractor Signature
Date
•
•
Ziful-
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FURNACE /AC
PERMIT APPLICATION FORM J
APN #Date:
3 I le oc)l
Building Address:
co3as Perm Tree Lo.,t
Owner's Na W mo
Phone #:
MECHANICAL
Or i oZy �-1
C
ntractor: r l r
S 1` U� M b v 1 QCT } \
1'S
License #: V `3
0
Contact,
hone :
BREMAIRHAN
A/C Units <= 10, 000 cfm
Applicani Contractor:
BREMRECEPT
Building Permit Info:
Bldg Elect Plumb Mech
Job Description:
Residential: fu fCommercial:
Sq.Ft. Floor Area:
$/Sq.Ft.: '
Architect/Engineer:
Valuation:
Type of Construction:
Occupancy Group:
Qty. if
ADolicable
Fee. itl
BENERGY
Energy
BUILIDNG
BREMFURN
Relocation of Furnaco
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
x MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMITFEE
Plumbing Permit Issue
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG
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