03070008 (2) IC ITY OF CUPEirl'INO
ACONTRAMRNFORMATJO§�
BUILDING DIVISION '.f
MIT
PER
BUILDING ADDRESS: ATLAS HEATING PERMIT"03070008
1 Gn-A T.A PT.AyA CM
OWNERS NAME: 155 SAN LAZARO AVE
KERTH RRTKPN 07/01 /9.0n';
NE: (408) 739-0516 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINF
BLDG ELECT PLUMB MECH
AM,
�00 LICENSED CONTRACTOR'S DECLARATION
�U- I herchyad that I mo licensed motor Provisions Of Chapter 9(Commencing Job Description
with Section 7000)"'rDivi.on 3 Arco,B d f * C%;..dirnylic.osci,
;<U full REPLACE FURNACE
0 in coca And
_:AL
on C
Pj- - T- can mse
ARCHITECrs Dwessituarl
1 molooss.nd my be used As public rttnrd,
A.t; UC.O.d Professional
i'0 1 OWNER-BUILDER DECLARATION
-<E I hereby effort,that I am exempt from the Coninscooes License Law for the
COO following mason.(Section 7031.5,Business and Prodficamons Code:Any city or county ra
which na,u1nat A Permit it)ofialmict.alter,improve,demolish,or repair structure agg Tli, U097
,He,to its iss..nc...Is.total.theit,,lic.ol lar.uch Permit 1.E,AlmgActim.w.col
that he is licensed pursuant to the provisions of the Contract.,'$Ucanm Low(Chapter 9 Sq. Ft. Floor Area
Valuation
yl-a (commencing with Section 7")of Division 3 Of the B amnom and Professions Code)or
that he Is exempt therefrom and the basis for the alleged exemption.Any violad,on of 35623008 . 00
Section 7031.5 by any applicant for a pormit subjects the applicant to a civil penally of APN Number Occupancy Type
not more do.For,hundred dollars(M).
❑1.nowneT of the prolixity,army employees with cages their sole compensation,
will do the work,and the structura isnot fimmdcd At offered f...)a(Sec.7W.Business - ROUGH t, ns
it Professions Code:no Conoratmor's License Law does not apply to an owner of
property who buildsor Improves thereon,and who doessuch work himself or through his 303 - ROUGH
own employees,provided that such firprovaments mrs,not Intended or offered ror Asia.If, 304 - ROUGH ELECTRICAL
however.the building or improvement is sold within one year or completion.the owner-
builder will have the burden of proving that he did not Wild or improo,for purpose of 505 - FINAL ELECTRICAL
.1.1 507 - FINAL PLUMBING
0 L as Owner of the properly,am exclusively contracting with licensed contractors to
Construct the prejact(Sec.7B44,Business end Normal...C.dA:)no C.Atracuo'k Lt. 508 - FINAL MECHANICAL
came Law does not apply to an owner or property who builds or Improves themon,and
who contracts for such projects with a commoor(s)licensed pursuant to the Contractor'.
License Law.
0 1 son exempt under Sec. B&P C for this mason
Owner Dow
WORKER'S COMPENSATION DECLARATION
I hereby arm under Penalty Of perjury One Of the following doCIAMIOng:
I have and will maintain.Corfifient.of Consent to self-insure for Worlaces Compen.
sation,As provided for by Section 37M of the Labor Code,for line perforimance,Of the
work for which this Permit is issued.
I have and will maintain Worker's Compensation Insurainca,a required by Section
137W of to,Labor Code.for dm poffmorance of the work for which this pirrod,is issued.
My
My W=Com=� Iion=Insum=carrier and Policy number am:
Co. Abcy,..:_O L?`LC_43,522;0
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi section need no,becomplewdifthe riannit i.fico..hunted dollars($100)
ICU.)
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner so as to become subjeat to the Workers Con,tcAmation
Laws of California.Data
Applicant
NOTICE TO APPLICANT If.after making this Certificate of Exemption.you should
become subject in me Worker's Compensation provisions of the Labor Code,you mum
z forthwith comply with such ponvisions or this Permit$1ball Ito damned invoked,
z 0
CONSTRUCTION LENDING AGENCY
I therapy afrom do,dom is a Construction lending agency for the pcirfiturnarox,of
the,work for which this permit is issued(So,.5197.Civ.C.)
Lander'.Name
z Lam&,'.Add.
0 1 comfy that I love mad this application and some that the above inroboadua is
F correct.I agree to comply with all city and county ordinances and sum Is"miming to
DU building construction,and hereby mutharim nalmammatives Ardis,city to enter upon the
above-mentioned property for ituracdon purposes.
(We)agree to an,indemnify and keep harmless do,City or Cupertino against
liabilities,judgments,costs and expenses;which may in any way accrue against mid City
U Z inconsequence oftie gaming athis per it
APPLICAN'T UNWRSTANDSA LL COb Y W11H ALL NON-POINT Issued by: Date
SOURCE REG ION
Re-roofs
Signature rAppIic..tJC.Avr.bo
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dOccupant o,applicant or future building store or handle hatarcous material
Dat
Gain
As defined by the Calendar,Municipal Code,Chapter 9,12,and the Health and Safety
ode,SAO..25532(a)?
C]Y. 944or— All roofs shall be inspected prior to any roofing material being installed,
Will the applicant or falum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
It hazardous air contaminants as aefincd by the Bay Area Air Quality MAns'ament all new materials for inspection.
oyes 244T—
I have mad the Woullousmatersils requirements under Chapter 6.95 of me C41ifor.
Tia Health&SafctyCO&.Socumns 25505,25533 and 25534.1 understand thatifulic building
does not Currently have a tenant,dial it is my remponsibility to nodly the Occupant of the
mquismacno,which st be nn:p I;a. fce. C roam ofaempggc Signature of Applicant Date
4 I 0_3
Owner ora r o t ateAll roof coverings to be Class "B"or better
CITY OF CUPERTINO v3 G o
Ga ' FURNACE/AC
CIT
CUPERTINO PERMIT APPLICATION FORM
APN#
j / D
Building Address:
�c,, PLcL,, '
Owner's e: . Phone#:
Contra or hone: License#:
eat Z 7 - s / G VGs zd 6
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Desc • tion:
e c�c ce- —CW, 000 6-ru
Residential Commercial ❑
For Residential In tallations:
Attic 13151 floor LJ 2nd floor❑
Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy r up
192 7. o-a
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floo ea:
New Location ❑ Replacement
Qty. if .
Applic0b1c, Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
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
1 BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
1 MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMII'FEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
� i ° 7. 9