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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
;gCONTRACTOR�INF.ORMATIRN:
BUILDING ADDRESS:
POOL SCENE INC
PIRMIINOO5080075
18000 CHELMSFORD WAY
R'S NAME:
PERMIT ISSUE DATE
RANCHO RINCANADA PARK DIST
ICT8100 CARMENCITA AVE
08/10/2005
E:
SANITARY NO. CONTROL NO.
(916)681-5353
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,IITEC flENGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
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LICENSED CONT'RACTOR'S DECLARATION
Job Description
1 hcmby affirm 'hat 1 am licensed under provisions or Chapter 9 (commcnciny
with suction 70(M) of Division 3 of the Busing tad Professions Code-, and my license is
in mu fora add affect.
REVISION -PARKING TO MEET TITLE 24
Licene Class Lk.,
Dau; Contactor
ARCHTIECTS DECLARATION
1 undesuand my plans shall be used u public records
Licensed Profcuianal
OWNER -BUILDER DECLARATION
C
1 hereby affirm mot 1 [Dust. from the Convector's Co License Law for the
'v
\
Maso 1.
191131.5, Business and , dicaov Cone: Any city structure
fallowing reason Permit no repair any swmum
alley, imforsu
which requires a permit re cons,
I
$0
h Permed suemem
prior to slissuance,aBarequite. the applicant for such Permit m RIca
the
Sq. F[. Floor Area
Valuation
cnelaw (Chapter
ta'Wiscing,witpur.an'mtc previsionso Law
odo ftCantrxand Cskc) of
(commencing with Remind 1n W) of Division 3O Ina and
alleged on. Any
that he u uernp"Wrtfrom and IK esti for the Wegcd exemption. Any viOladon of
Occupancy Type
Section 1031.5 by any applicant for a Permit subjces the applicant to a civil penalty of
not more tan five hundred dollars (SSW).
I, as owner of the property, army employceswith wage.. timu sulc compemNOn,
Required Inspections
will do me work and to Nucture is not intended or offered for sale (Sec. 1014. Business
and Prefessiav Codc: The Conuacmri Licmese Law docs not apply to an owner of
property who builds or improwa Ramon, and who doea such work himself or trough his
Own cmployeex, provided tha'such improvemems are not intended or offered for sant, IL
however, to building or improvement is sold within am you of completion, the awttcr-
builder will luve'he burden of proving that Im did not build or improve for purpose of
.le.).
r1, as Owner of the propeny, am exclusively counseling with licensed 1V nlracrors to
onavac' the PMjcm (Sec. Trod. Business and Profusions Codc:) The Contractor's Li.
came Lawdors no' appl der of pr ny who Wilds or improve Orman. and,
who con'racuforauch ojccu witaca nm,(I)Li dud pursuanl m the Canuumfa
C eveaw
am�n pw— kPC for this resod
Dau to
- - WORKER'S OMPENSATION DECLARATION
1 hereby affirm under penalty of pedt ry One of the following declarations:
save and will maintain • Certificate or Consent to self-mma, for Worker's Compen-
.t, . provided for by Section 39W of to labor Cod, for the performance of the
work for which this permit is issued.
1 nave and will maintain Warkera COmperuation Insurance, . required by Ration
37W of the labor Code. for the performance of the work for which this permit is issued.
My Workers Compensation Wo rams cattier and Policy number all:
Caller. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This =am need not he completed Kthe permit is for one hundred dollars ($IN))
or Ice.)
1 ccnify mm in Oc performance of the work (or which this Permit Is issued, l shall not
dn)'pet. f . W e�bjpgt.IBJQc Wdrk[IS Compensation
LaplOy
laws of Calif au ,t ttJJVV�srr
l.L
ApplIICE
CE TO Nf: If. making thisCertificate Exemption, you should
NOTafter
become subject in me WoerCompensation provisoes or me Lahr Cade, you men
' forthwith comply with such Provisions or thispermit hall M ticcmcd revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat mere is construction lending agency for to Performance of
' work fur which Nis permit is issued (Sec. 3099. Civ. C.)
the s
'
Lendeders Nene
,
1<nderi Atlartu
j 1 certify Nat 1 have read this application and sum tat the above mfonnariun Is
' cO'meL 1 agree to comply with all city and county ordinances and sum laws relating to
building construction, and hereby aumorire repreenutives of this city to enter upon tM
above-mentioned property for impaction purposes.
(We) agree to save, indemnify and keep hum less the City of Cupertino against
j liabilitiu,judgmm(mo. cases and cabmen which may in any way acct.[ against Mid City
Inu spending tc .n'ing of this penult.
PLI UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S GU ATI S.
Re -roofs
1O
fAppIiCWUCOa=mr Dau
HAZARDOUS MATERIALS DISCLOSURE
Type Of Roof
Will the applicant or future building Occupant store or handle hazardous material
ex dermad by the Cupertino Municipal Code. Chapter 9.12, end the Health end Safety
e, soden 25532(.)? '
All roofs shall be inspected prior to any roofing material being installed.
❑Yes '
If a roof is installed without first obtaining an inspection, I agree to remove
Will the still eam ar mmre building =upon, equipment or which
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haiaranw air contaminants aa defined by tW Bay Arta Air Quality Management
a it Qu Mann
all new materials for inspection.
ire?
❑Yes �u
I have mad the hnardnus materials rusimmmcnu under Chapter 6.95 of the Califon
niaH myCode, Seeuov 25505.25533 and 25534. 1 understand 0. ifthe Wilding
d s no fnnently ha a tenon', tm it is my responsibility, to nouly me Occupant of me
re eswbirn R etPdnf"i.ameear,CenircauorQeapanay.
Signature of Applicant Date
_
�6 �^-''� 2004
All roof coverings to be Class "B" or better
Owner of authoriacd sgent Dale-