04080080 (2) CITY OF CUPERTINO N g,;
BUILDING DIVISION PERMIT 4C oXtTRAaIt"OR INV AT,
BUILDING ADDRESS: PERMITN
SWAN POOLS `1)4080080
A PERMIT ISSUE DATE
P,ON SANITARY NO. CONTROL NO.
HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMR MEC"
] CD O O
+lp Z, LICENSED CONTRACTOR'S DECLARATION Job Description
�u 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
a with Section 70M)of Division 3 Orrin Business and Professions Code,and my license is
co : ata effect. POOL & SPA cIun.a
�- D01 G'S DEC` 1/19/05 PERMIT FINALED IN ERROR. STILL NEEDS G
Fq ARCHITECTS DECLARATION
rya IunderhandmyplmsshNheused..p.hit.seemds TEST-WRONG METER SIZE .
a
3p
Licensed Pmfcuional
OWNER-BUILDER DECLARATION
<I I hereby affirm the[11. exempt s an the Cnnlrac[Co License Law for the
folq 0
which
requires a Permit(Sectit 'R13L4 Business and Proimprove.
de ons Code:Any tiny or manly
which rcyuhes a Permit re conalquires the
elks imprrsu h remit i fie pair any structure
r y Lrionnits censed e.also prsuntI.ths@c.pions of for Cchpermiuofdcuignwdi(Chapteant
£5< (that he commetcingwJpu,,uammthepmvivision3the ortheBuacmrindProelsw(Chodter9 Sq.Ft. Floor Area Valuation
y $ (cd,he
exempt
hecto,, and
Diviaion3 oralegeinexempton.Any
Code)or
�.. Nal he is exempt therefrom and the buU for the alleged exemption.Any violation of 833000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of APN Number Occupancy Type
not mom than five hundred della,,($500).
❑I.as owner of the property,in my employees with wages as their sole compensation,
will do the work.and the suucture is not Intended or offered for sale(Soc,rots.Business 3263901300
and Prefesalon.Code:The Cono .
selm's License Law does not apply to an owner of Required Inspections
property who bulletor improve.thereon,and whodoesi uch work hlmselforthrough his
Own employees.the
ebuiprovided proveat such Improvements are non year
completion.
fordue Owner.however,Ne building arimprovementissold within oneyear of comPle for Ne owner
builder will have the burden of proving Net he did not build or improve for purpose of
sale.).
p 1,as owner of the properly.am exclusively contracting with licensed conlracrora to
come Law
the project`Sec.o in weerBusiof and ny wh ions Cods:)i The Contractor's the ton,and mux Law coca not apply ro ts owner of property who builds or improves thereon,and /
whocontractsLacts for such projects with a contractor(s)licenxe pursuant to the Contnctoh
Licence law. J
❑1 em exempt antler gee. ,B&P C for this recon
Owner Dane
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,one of the following declarations:
Ifthaft and will maintain aCenifinle of Consent o self-insum rat Worker's Compere
u provided for by Section 3700 of the Labor Code,for the performance of the
for which his .it is Ounce.
1 have and will maintain Worker's Compensation Insurance,M required by Section
37M of the Labor Code,for she performance of the work for which[his permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Caner: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed iDhe Permit is furore hundred dollars(SIM)
or less.) ,
1 ceniry that In the perfmmanee of the work for which this permit Is Issued.I shall not
employ any Lenon In any manner sir u to become subject to the Workers'Compensation
Lt.or California.Dale
Applicant
NOTICE TO APPLICANT:if,after making this Cen10cale or Exemption,you should
became subject to the Worker's Compensation provisions or Ne Labor Code,you must
.JO forthwith comply with such provisions or this pereall shall he deemed revoked.
Zy CONSTRUCTION LENDING AGENCY
'f•+ I hereby affirm Nal there is a construction lending agency fnr the performance of
gY> the work fur which this permit It Issued(Sex.3091,Civ.C.)
W� A Lender's Name
a 7. Lender's Address
U Q I certify that I have read this application and cele that the above Infomtanion is
{fn F emrem.I agree no comply with all city and county ordinances and state laws relating to
QU buildingemmineoioq and hereby art[bed.mpreaenmlivea of lMs city In cmerupnn the
I17 ahovcmentiuned property for inspection purposes
gy (We)agree to cave,indemnify and keep harmless the City of Cu,ulhm against
rt rmit. 170
rat liabilities,judgments,costs and expenses which may In any way accmc against said City
In
his
V APPLICANTcUNDERSTANDSof the gracting ofIAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS, S �(.a
Re-roofs
HAZARDOUS
Signature of ApplicarDate m US MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building occupantstore orand th Health
althamaterial
u defined by the Cupertino Municipal Code.Chapter 9.11,and the Hcelth end Safety
Code.Settles 25532(.)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
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
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for Inspection.
ict7
❑Yes ON.
1 hat read the havardous materials requirements under Chaporrii.95 orthe Calif ir-
nulicalth&Safety Code,Seedons25505,25533 and 25534.1 understand thetifthe building
does not currently hove a Nn.nt,that it is my respomlMllly in notify the mcupanl of the
requirements which mustM met prior to issuance ofa Certificate,of Occupancy. Signature Of Applicant Date
Owner ratinthimneedagent Dam All roof coverings to be Class"B"or better