04080080 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C,0NTRACT,0P jNA RMATIO�N
BUII.DINGADDRESS: SWAN POOLS PERMIT NO.
O4OSOOHO
C110 QAKNC)TT CT
ER'S NAME: PERMIT LSUE DATE
ONE:
SANITARY 0 OL NO.
ARCHIIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
i with Sanson]Offf of Division 3 of fest Busing and Professions Code,and my liccnm is
'n<a in full forte�i IT t-
LicrnSe Cl. L� g POOL & SPA
Cuntmcmr
` / ARCHITECTS DECIA I(t3l)N!
11035=nlmy plans SM11 he used repuhbe astride
�yU
;oH Licensed Professional
` g Oat I the .rfrUILDER DECLARATION
<E I hereby.limn on 1 1. cxumpt from the Conan Cod License Law for the .
00 which
following reason.($atilt]o s r Business and improve.
desmon CMG: ,.I,Stay li county
which requires a permit to cnnatrvce,alter.int for Such
Mromit t,file
repair any strvedure
m_y pdmeiucensed issuance, 10 the the applicant for mchlarmiuo xonere Law
statement
ex shat me cccnsed pursuant 7 the of Division
of dm Contractor's Liccnu Law(C orti or Sq.F[. Floor Area VaIU LI00
�FC
that
ixemith Section dDiviaion3 tof he al Business prion.nd Professors CnM)of
utas he u,seeps fecmfrom and the baso for the alleged exemption.My violation Of
Section 7031.5 by v0 applicant for a permit subjccu the applicant to a civil penalty of 3 �iy1�I�erpp ane Occu Type
not more thanfiwhundred delta.($s00). Occupancy ,
I,M owacr of fee propany,or my employees wife wages u their sole compensation,
will do the work and are suuedum is not intended or offered for sem(Sec.7044,Busincer
and Professions Code:The Contractor's License Law does not apply to an owner of _ Required Inspections
ownproproy,
mployebuilds mimprovu theroogand who daensr mounted
kheoffred forsgh his ry rs���®ownsexi staffed saM1impmwmauarene leu of co plidod the ower- t��s�p"tI'{qf
however,the building or enoft Improvement is sold within one yearfe completion,the owner- V
builder will have Ne burden of proving utas he did not build Or improve for purpose of
sa1c).
I,as Owner of the properly,am exclusively conferring wife licensed conaaetors to tt 2005
common 4
Ne limited(Sec.701 .Business and Professions Code:)The JA
Contractors Li.
Genu law data not apply to an owner of property who builds or imps es thereon,and
who cantrscu for such pmjeets wife a co usecter(s)licensed pursuant to Nc Contractor's
LiccnSe Law. t�(I p I O ®I N /..�
1 am exempt under Sea ,B 6 P C for this mason tlt/��ll 1p��/Np IlG(ka Iryt`�C/a//
a Dam
WORKER'S COMPENSATION DECLARATION
1 threby affirm under penally of perjury,ane of tate following dalanuatu:
I haw and will maintain a Certificate of Cement a Self-insure for WorkersComrcn-
,tion,u provided for by Section 37W of fee labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Work nes Compensation Insurance,as acquired by Section
]W of the labor Code,for the perfentance of the work for which this permit is issued.
My Workers Compensation hear tic carrier and Policy res.1W,vi
Carver.A. CE A. Policy ROXIV • Q�
J CERTIFIC COMPENSATION ON FRA RKERS'
COMPENSATION INSURANCE
(IDia ecelian need not W completed if the permit is resume hundred Malars($100)
or less.)
1 certify that in the performance of etc work for which this permit is issued,1 shall not
employ any person in any mannerso as Or freome subjced to the Worrecos Compcmation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker i Compensation previsions of the Labor CnM,you muse
.JO forthwith comply with Such Pmm virinor this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hereby aRrm that there is a construction lending agency for the pedurmena of
a Ne work for which this permit is issued(Sec.309],Co.C.)
QI<Mcls Name
z Lender's Address
U Q 1 ccnify that 1 have read this application and Stuart that the above Information IS ,
Iy F^ corrett I agree to comply with all city and county Ordinances and sum laws relating to
p C.7 building construction,and hereby authorim repntsrmatiws of this city to enter Open s¢
ahOw'dormiuncl property for inspection furriers.
F y (We)agree he Saw,led cmnify and keep harmless the City of Cuper iso agaiest
p3 liabilida.judgromms,wsu and caricatures which may in anyway accec against said City
Us. in consequence of the granting of this permit. / C
'—' APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATION
�""°I I g Re-roofs l
Elft PVI AZARDOUS 1ATERIA DISCLOSURE �— Type of Roof
Will fee applmart or future ilJing occupant store or handle haudous material
as defined by thc Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Section 35533(x)?
❑Ys All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
y emit hanrdous air contaminants u defined by the Bay Arca Air Quality Managcmrm
District? all new materials for inspection.
❑Yce pram
1havemadthehv smamrialsmquiremewunder Chapur6.95oftheCalifor-
niaRealMa Safely Code Scaom35X5,35533and2534.1undcrsmM .,fthc Wilding
Jaen of come ntly have a resent.utas it u reapro iltiloy to nobly tie occupant of the
mqu' creta ichmOnW CL44VIefurserecurricturiffeawisfaN rP Signature of Applicant Date
g
Ow rorautharivrd ret orD,m All roof coverings to be Class"B"or better