02030069 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
11042 FIRETHORNE DR SOUTH BAY REFRIGERATION 02030069
W NEWS NAME: APPLICATION SUB DATE
MARLENE PENNEY 461 PERRYMONT 03/14/2002
PHONE: -
(408) 279-1911 SANITARY NO. CONTROL NO.
ARCNITECTJENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION [Ing Job Description
z O I h by Rom Ih,1 T need under Prov s ons of Cha ter 9(con en
m zs unf ,1}'jR'l0(q)otn J tmeBoaXand Profn.on ernd<Tand yh[ena< REPLACE EXISTING FURNACE/CONDENSING UNIT
ad LL u L[e s<Clas. LiC . S U V 1
oa �� Co
rARCHITCCT''aLAR ON; ,•
-,c ''l '1 unEfisl?ria my Plans,&hall he uzcd as public resords;',
i x 0 O Licensed Professional
X�K OWNER-BUILDER DECLARATION
In_1 I hereby affirm that 1 on,exempt from the Contractor's License Law for the
following rcuon.(Section 7831.5.Business and Profen&ions Cede Any Illy or county
$3700 s F O which requires a parrot to conomet,alter,improve,demolish,or repair any structure
eaRm Pew,o its issuance also requiresthe applicant forsuch penni)mfie aaigned smmmem _
(hat he is licensed pursuant m the I......s,of the Contractor's Liccnsc Law(chapter 9
Icommencingwith secron70W)of Di,loan 3of the Raninesland Profe,ICore) ` yr;;<.(f;;'
.,that he is exempt Iberefomt'and the hoer,.for the allegca esemptimd.Any vintner ` r'�'` - f t�15 Valuation
of Seaian 7031.5 by any applicant fora penni,suhje,o the npplicam m e civil penalty
of awrc titan five hundred dollars(SSW). 204kPN"bERFLOOR 'F ME'` Occupancy Type
❑I.as owner cram property.m,toy employee,with wage,,,heir sale annperu.inn. _
will do'he work:and the store, I'is nm intended nr offered for sale(See 7841; -- -- - --- ROUGH
- _ .-
.. Btlaneak:and Pmfrwimn.Code:The Contra nms u[aaa Law does ten apply to an 303 - ROUGH M]R(4"Ir8Aik ions ' .
owner ofp pcwnrim b IJ. p tl d U c h work Ir 304 — ROUGH ELECTRICAL
ur lh gl h' npl S provided II I such' p I is n 1' 1 dcJ or
BRei df his
Irl the building 'pd e t s. IJ 'Ih year of - - _._ _ -..... .ROUGH..."_
amp)tan me aw der na uler Will have neburden arpmv ng that de a'a not baJam 505 — FINAL
improve for paryn6e arxale.). _ 507 — FINAL PLUMBING ,
❑1; flhe IsconIusivclY I i g withh .edc 1 Inn - ....
.:
construct
onsi t'hPI
[I Tee 7014,B .neo& d 1 raR6.an,Cade)The Contractor. 5 0 8 — F I NAli MECHANI CAL . _
License Law nae.not apply m an aw'ner mf property who milds ar impmvel Iherecn. 514 — FINAL PUBLIC WORKS
..and who.mnlmI.for such pmject&.wit a.contral licensed pursuant to to
CommaLicense Law.
❑lam exempt under Scc. ,B&PCfor
his reason. • ., 1tI
O rte
Date
WORKERS COMPENSATION DECLARATION
"t, t hf
eehy Rim u d pen IIY I p11 ry one f Ih to110 ng tletla , .
❑ I
he,a and xtll manmto o Cenifcae of Cuiro
essin to'self um for Porker's
Compensation, he provided for by Seniors 37W of ,he Labor,
Cone, for to
- porformance of the work for which this permit is issued.
137W - Worker's Compensation ran I h nd 11 am 'I
tlobo Code fee
t<pr . requiredyeno
issued Mylsok oma of the work forwhich thissenor is
u ?p0�
- a 4Jk[
cYN
CERTIFlCATIOY F.XF,Mp17oN FROM WORKE1t5
MP ENSATIONINSURANCE 'v t �' • ',y� N I• -•J ti -.'I. I`J .
: _CO -.. __ - t ..
's (This uaion'eced not be'tiomplaed if she Permit is for one hundred dollars
Iaserby that' the perf c ftwork'for which,his pc.it s .,ued-1
shall t employ a y Person in anymmmer,,a,nsto become subject w I the Wmrkeii i
Coope tet on LawCalifornia
s of Califo .Date '-
Applicani' '
NOTICETOAPPLICAN I 1 11111 ailingtlIscianificaneof Exempuon,You should
-- -- ---- -- - ------ - - -- - -- - - --- - --- - - -
Z become bj a the Workers C pen olio I s ns of the Labor Coils you'oil
0 0 fonhw t comply ilh such p or Nation hall be deemed related.
'P L4
w.� fade tf heHCthONpSeTrmRUlC'TIOd(Sc 3N0G9TC
lbreby.ffirnr,lba,Ih lsonal loodinj
IIg. . f nhe per- ace
C)
r -'
-
y.G
�. Lenders Names..
Z ntle Add — .... . ..._ ._ _
......
(sI I ccn Ty tha 1 hov ad Ih s app)tali I anJ auu ihm the bave infOnllnlimn is '
OF. coirecsT agree m comply Wind all cily':md county Ordinances and maelaws rel.im,
aV tO da11dI11g COn.INI11nn;Md11[ by yglhOri[C ICprC.enlallvC6 Of Int.CIly l4 enler Upon
�• [y the aM I J p upeny f mpcnion p I
F � :;t(w) g lo. e nJM y Jkeeph 1 '.tletiry fCuperi geinsl j— Date g ,said(J Z Gly in nceceof(liY- Y_WeY cm �Issued by:
'i acre of APPlidanV onuanor .,: '^ " me
1 Y pe p I Cafe,Chn rer 9 I'_.and the H hh and Ser Re-roofsHAZARDOUS MATERIALS DISCLOSURE
WII to ppl' I o f w b'ID'g ncc pant mrc n h ndl haraNOhs Ice -T eAf ROOF
azdeE edb th C nn M p IIY yP
. ❑vee' N n ? J �,
All roofs,shall be inspected prior to an rliofin
Will t applicant o f i bu Id' g occupant equipment a I mm - - Y. g. -It -al being Installed,
ant .arcmnmmmameasdefiledbythe Bay Ali.AirQumltyMinagemem If a roof Is installed without first obtaining an inspection, I agree,to"remove
Emotes' all new materials for inspection. Applicant understands and will Comply with
(� oY P Y -----. - .
o"a all non-point source"regulations.
'
I base read,h bsanrdnus mmmW gmman under Chapter 695 of to
CaliforniaH IIb afe,y Code Sttuma 550525537 and 255341under&undthat
'Doty tly hov t ant:,ha,it is my responsibility lO notify t<
tits bmltng v mme1is'v'hic mu me,Pelona issuance of a Cenifi
e. Occu,nae jr .. `
Signature of Applicant Date
Own r autarizW agdnr Lee . All roof coverings to be Class "B"or better -
".:..;
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