01110101 (2) CI BU
BUILDING DISCUPESIIONNO
IPERMIT CONTRACTOR INFORMATION::
BUILDING ADDRESS: PERMIT NO.
7887 FIESTA LN SOUTH BAY REFRIGERATION 01110101
OWNER'S NAME: APPLICATION SUB DATE
WORLEY ORVILLE C TRUSTEE 461 PERRYMONT 11/21/2001
PHONE: (408) 279-1911 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a'6 = LJ L__J IL=7
m— I heronaffirmLICENSED
m,aha EDm licensed under provisions DECLARATION 9(commencing Job Description
„t with Section 7 ) fDnuion3oftheBusinesskssionsCode,admynceaxv REPLACE FURNACE WITH 70000BTU.
S m s is la rml cera ana
z w< Liense Clas, f 20 Lic.g ^ 3
c 3 a V so
Dae 5 DECLmr
(J ✓ ARCHITECT'S DECLAR
-'—`w 4 1 undcntand my plans shall be used m pubrd "
ne
O C Licensed Professional
a OWNER-BUILDER DECLARATION
u�='I 1 hammy atfnn that I am exempt from the Ccr.oai'+License Law(or the
?efallowing ream..(Section 7031.5.Business and Professions Case:Any city or county
which requires a permit t corwouct.alter.improse.demolish, repair any structure $1900
a 3. Prior 90 its issuance.also requires the ppl' t for such Proud,10 file a signed statement
that h licensed uniumi t thi iiFinisions ofde Commons License LaIChager9
(emm r is withs t 701)(0)of Division 3 fl B ndr .ra Cade) t•'k;'h:'d k.3'� .t3i�,�B�;'°(� p'; 6i 9 I"j,f',`,, • Valuation
or that he s exempt thcreGom and the ba..s far the alleged ase option.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty "PN
p w��,�
[of not mom than five hundred dollars(a5w). 30J.-Nlsk6 �iH PLUMBIN Occupancy Type
❑1,as owner of ibe propcny,or my employees with wages as their sole compensation,
-will do the work and the structure is not intended or offered far sale-(Sev.'7WA,'
Business and Profis,ians Cade:The Contractor',urease Law des not apply to an 304 - ROUGH E$I *R-1ffC1%1Stions r"
owner ofproperly,Who build,or improves therton,and who does such work himself
orthroughh' plye provided th, n Pa are t intendeda 505___7, FINAL ELECTRICAL
offered far 1 If however.th bind g p t Id th -
'molt thowner-builderRM1 me WN rp ' gthtn a'a tele ` 507 — FINAL PLUMBING "f
cep f prpmir I ) 508 — FINAL MECHANICAL
01 <r of-the pr,
opny am exclusively cormictiogth licensed continictors i
on matt the project(S 7 W4 Business and Professions Code:)The Contractor's
License Law bas no,apply to fp pent who builds or-orpoosestherean,aC
Contmmolsse
❑I mreau `or uch projects.wW.a.contraciabin-1¢emed.pursuant to.,h .._._ ___. ._. 'VJ
and ba es mactLicens /O�-
aei n der Scc.', _ ,B'&P C for this reason
_ Owner I' Gant,
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
O 1 have and will maintain a Cenificam of Consent to self-insure for Worker's
l Compensation, as provided for by Section 1700 of ,he Labor Csxle, for the
Performance of the work for which this Penni,is issued.
O 1 have and will maintain Worker's Compensation Insurance,az required by Section
37W of,he tabor Code,(a,the performance of the work for which this permit is
issued.My Wok .i Cirtnite.s.lon,Insurance -er.d_PoI y sober oro
....�PolicY No:'Kl /✓�.Q ��` ` I - _,__-_.
u 1.CERTIFICATION OF EXEMPTION FROM WORKERS': t ,1': ' \ '. .
'COMPENSATION INSURANCE''-s" ' �-
'' '^ (Thisssci�tion need no,be cnmpincd if the p<mai,is for one hundred dollars }`� '' �'''t" r'- �� -----.._-_.
j1F
tempoyhtinthpef Y,hb 'kf .. ,-. - -...
'shall no,em to - which u pe' 't sorke,l -
p y any Person m any manner so az to become sub)cn to the Workers - t
Compensation Laws of California.Da¢" '
NOTICE TOAPPLICANT If,after making this Certificate of Epi you should
o
z becex hj a @eta k C pe ei previsions oft. Lan Coe y u most '
Q faiih-lhc mply l_schp sn ,or,has permit thaili be deemed reoked.
' lo,Iyy CONSTRUCTION LENDING AGENCY _
1P...I hereby Rrm sh ah - canals n lending agency f the performance
,..t
......
f the work for which thperm t' issued(Sec 3097 Civ.C) "
C 'Leade ,Name .... ......:. -.: .:. ...__.-__ _.. _... ... _. .._. ._ ___. _.-.. ._._._.... ..
Lend "'Address "
. 1 ccmf)that i have mark this applicat o d It-ac that the ithom information is
'[.., coat'.'agree to comply with all city ana county ordinances ane,tate laws Mating
C'.r, in building construc,icatand hereby authorize mpresentatiJes of this city to enter upon
Wthe abovementioned propey for;'pection puspoms.
[:n Oa (WOrigreeto ave.indemnify and keep harmless the City of Cupcnino against
ZZ' liabilities,judg,�e ,ants and expenus which they in any way'terve.,ain't said
V z City,'cons qts fthc gmming of thi [ ..
4PPLIC NDEBFT EC OMPLYWITHALLNON:POINr 1
yrIssued by: Dale
A,l rmA t t HAZAF.DOUS MATERIALS DISCLOSVRE I i' � Re-roofs
Will the ppl cant m future bu Id' g occupant tom or handl hoard us s¢'al .Type Of Roof
of m by th Cupen Municipal Code Ch Chapter 9 12 ❑the Health d Safety - - .' . : _."...,. I--
,— /. V-.
asd00
oidc Sect on 2551 lel+ Tt .+ ,Z-., -, , .,. I .. -
-
❑Ys ' ❑u .. l .1' ;t lilt JAI ) ). s. n '. 3 +'.
-rli _. All.roofs,shall.be inspected prior-[o any roofing material.being installed.
Will the applicant f t bull gnythe
a ant me equipment ee 'e,when If a roof is installed without first obtaining am ins ection;I agree.to!remove
emit n:m' x a r contaminants as sell ns m Bey Area A, o alty M.'&amen, g P
°""
p'' Y 0 N all new materials for inspection. Applicant understands and will_comply_with.
y,. all non-poinf source regulations._
,pP. tn'
1 have read'the huriAndons mmerials mqu rcments'uade Chapter K95+of the
Califom,a Health&5 Code,Senibnx 25505,25533 and 25530.1 undcrnand that
inh2hueding eoce n mly havea¢nant.In
tenant. is myrcsponsibilirybunity be
occupant of a re rements which muss be me!'n I i"tain sof a Cenificate of '
' Signature of Applicant Date
aamonaeaagent I " Do,,,,. All roof coverings to be Class "B" or better
OFFICE-