01060084 CITY OF CUPERTINO
BUILDING]DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
11289 TERRA BELLA DR SOUTH BAY REFRIGERATION 01060084
OWNER'S NAME: APPLICATION.gUB DATE
TOMPKINS KATHLEEN S AND JOHN 461 PERRYMONT 06/14/ 2001
PHONE: (408) 279-1911 SANITARY NO. CONTROL NO.
WC ncZARCHITECT/ENGINEER: BUILDING PERMIT INFO
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g w C BLDG ELECT PLUMB ECH
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,Cr,_ LICENSED CONTRACTOR'S DECLARATION -
z 5„ Job Description
D�_� hertbya(ErmNmlamliccn JunderproviaionsofChaprer9(comme ing REPLACE EXISTING FURNACE.
rote wi ion l0001of Divi.sion3ofthe Business and Pmfeaions Cede,and my license
y In full forte a t.
5�a Licemi s Lie.. �� G _ WITH 90000 BTU FURNACE SAME SIZE.
X 3 Dae Contrecmr
ARCHITECT'S DECLARATION
E' g 1 understand my plans shall be used as public records
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up O Licensed Pmfcssiowl
o OWNER-BUILDER DECLARATION
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1 hereby aSoc ,ha,1 am exempt from,he Contractor's r'a License law for the
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following rc a IS.i n 703 LS B ' d P f. Cade Any my or county,
which q a pert)t N con, id he p J I h rep, any structure
'� pro , t a1. gireL idol tf wbre ilio grcd(Chapter
- - .. _. -_ _ ...
omh gwith :oitautbep tn.oldieContractor's bs W on,Cds) �85
modSc Ft:Floor Are I Valuation
a. n I,exem 5u, n,m(MIhit hbDivision J enh.Bided e d Profession,vi Cwle) f7 I "_!.♦ :.•• : _t
or that he ix exempi,hercfmm'ahJ the basis Notion ellegeil exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
;of no,m.re Nan Eve hundred dollar,(ssan. A umber i -r•'r,7 Occupancy Type
❑I,a,.wbe,.f,he propeny,or my cmpmyeea wird wages as their sole compensation,
—,will do the work:and the structure is no,intended or offered for sale(Sec.76u, - --
'Busirieas acid professions Cale:The Contractor's License law dwes not apply to an 303 - ROUGH MEIFKi' Nd C Aftctions'""
owns,of propeny Who Wilda or improves,here...and who does such work himself
or through his own employees,provided that such improvements are not intended or 3 04 - ROUGH ELECTRICAL
...offered for sale IL ho%pi eC.,he buddin t n sold rithin one ..._fs' _..__._..—
gwimpn of pro rgldo 505 - FINAL ELECTRICAL'- ' �`'f11 `
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,Completion,the owner-Wildcrwill have the Wrdcnaf ,ha he not Wild or
ELECTRICAL - -
i reprove for pu,p.se of sale.). proving 507 - FINAL PLUMBING 1
❑I,as owner of, propeny,am exclusively contracting with licensee conuacrors m
'508-�--- 'FINAL ME HAN A 1, '„ .,,
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))Saud e proj (Sec.71 ,Business and Professions Code:)The Contractor's
License Law Joex ect no,applyw1to an owner of property w!lo Wilds or improves thereon,
.and.who camracts.for such projects.wim.o.comru,or(s).licensed..pursuant It the
Committees License.Law..,,.,..., I)r"..'r1 JP
❑lam exempt under See." - 1 •t 'A'''BA&PCfor,his reason •'s`
whir
WORKER'S COMPENSATION DECLARATION
I hereby affirm unJcr pcnahy of perjury mit°fyhe following declarations:
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❑ 1 have and will maintain'.Celinddi a of Cowan,to self mxxma for Worker', 'sr �. LOO
Compensation, air provided for by Section 37W or Ne Labs Caste, for the
perm ndaide.fine work forwhich,his plord,is issued.,l,
❑I have and will maintain Woduces Compcn'sadbmIriioidn8,ss requiml by Scnion BUILDING
1 ode fo N perform f the oh fwhich thispetrol,is
Came. Crepe . Instant e<rte 'MPolryd berrc
ti d My W 4fi
`^ aQ-I' � 1 yry 4JGCh'!D/S.2l.11 . ...ti -TI t. f'+ 1.• �CAe{} .t17 ....._.. ... _._._.__._
r CLRTIFICATION O EXLMI'f10N FROM WORKERS{ " ' a t
COMPENSATION INSURANCE ' ,. ...__. ... _ ..�_... _ ._—. � ,-.f ___
A i, \..�1• IPI . " nf'.a". , I\'�1;'
(This aecu.n need no,bb complcieJ tithe permit is for one hunJrcJ dollars
IS 1001wIess.1
� ' T`I cenify Nm in Ne,perfo'rmance of me work for which Nis petrol,is issued.1 - � - -. _.,.� .. -�- �*-� -- — --. .� u is, 1
ahall'but employ any,person,n any manner,..as to become-subject,o the Wwkni t'..1 :a i ! .J 1-°C !'P.`
A Icm - °fc,lf Date - I
V Apphe ETOAPNLI.
Co f L ors
CANT It al¢r making th's Ccn❑cmc of Exemption,you should
heceme subjecun the Worker.,Cwnpensaunn pinvis ons.I the Labor Code,you must '
Q ronhwith tom with such provisions io his permit shall be deemed revoked. t
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CONSTRUCTION LENDING AGENCY ' I a, "• 1
I hereby affirm that there is a coni roction lending agency for the performance
of the warl,f hich,h.pc tis sued(Sec 3097 Ci,C.)
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.7.Z. Ild Add .,
V i vertify tall l have read Ild uppli , n and.,,e that W formation is
curt , I ago,cmeumpl)with III.,city and county odinancs and oxof law,relating
to WilJl)g ronsvuciinn.and hereby.imnorim iep nta,ivcs of Nis thyro enter upon
he above mcntmnad,property for inpcai� v'
;Cons,
e)agreem. .indemnify and c! nnnieis thecity of Cupertino against
h liabilitjudgment:cobs an mien w nth may in any way accrue regains,said
U'Z Ci,-inyu ofihc bra "Sof iyERSfAN '. ND O)fPLY WITHALL N P I:°f" Issued by: Date
UR -sl ATIONS: ),. , iq�
Signmurt Df Applicam7Commcmr
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Re-roofs
wum applicant m, Wdd ICipart d Sfbard am criaTYPe of R
oofH\7\RDOUS hALRLSD15CLOURE'
as didfiro,d 4y,hc C.Femno Mtraicilsid Code.Ch,oer 9.12,and the Health add Safety
Code,Semon 2532w?.
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r O N _ .,)
'� - t All roofs shall be inspected poor to any roofingmaterial being installed.. _„-
„
Will thc pplicamarf, buId' ,nectifunat muee,iiijornardiodevice,xecn If a roof Is installed without first obtaining an inspection, Pagreeao remove
emu ha N s c° w nan, as dein dby,h Bay ArteA Qmlity hl...gement
D', _ I all new materials for inspection.__Applicant understands and.will comply.with
ANoall non-pointsource regulations.e r<ud't huLardodi mar5ril. rcyuircmcros.anJer enapmr6.9f nb Ncat, afe,yCodeSectio 25505i55D ane 2553,.PunJert,anJ Natng- mcurtenJyh a namnhat i,is my'respersinility to notify the
cadre) ,e t x h”h m be mci,prim,o issuance of a C<md cnte of
men Signature of Applicant _ _ Date
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ow ern: m.d:mdgem 1 „e' All roof coverings to be Class"B” or better
OFFICE _ . ._