09020002 CITY OF CUPERTINO
BUILDING DIVISION PERMITT .
PERMIT NO.
BUILDING ADDRESS: ,
ROYAL POOLS 21350 VAI AVE
PERMIT LS6IIE DATE
'NER'S NAME: CLARA
S A CONTROL NO.
PHONE:
408371800
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATI Job Description
ra I hereby affirm that I am licensed under provisions of p�cr 9(tom cnctng
Z with Section 7000)of Division 3 of the Business and Proffe ssm Codc,and m ice i"''W RE S I DNT L POOL (IN—GROUND)
o y in full force an ?' "'
-Z License Clas Contractor
y Date
ARCHITECT'S DEC
1 undo d my plans shall be used as public Idcords /
L O in Licensed professional L
OWNER-BUILDER D LARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
NO following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Sq-Ft.Floor Area Valuation
—?< that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9
YF (commencing with Scction 7000)of Division 3 of the Business and Professions Code)or $26000
A .he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500)• 36205029 . 00
❑I,as owner of the property.or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed Contractors to
construct the project(Sec.7044,Business and Professions Code:)The Conuwwes Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec .B&P C for this reason
mer Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,f the performance of the work for which this permit is issued.
My Workers Com crus o rrsurance carrier and Polity number arc: ��
Carrier. �� Polity No.:
'Cr R77FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
p: the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
aZ Lender's Address
1 certify that 1 have read this application and state that the above information is
[UL cortccl-I agree to ply with all city and county ordinances and state laws relating to
U building cons son„and hereby authorize represenlativrs of this city to toter upon the
above-mentio ed prgperly for ins on purposes
>t a (Wc)igree saw,Inde i[y and keep less the City of Cupertino against
liabilities,' .costsan xpe which ay in any way accrue against said City
V z in conseq nee the grantin of ii
Date
APPLI NT NDERSTA DS WI OMPLY WITH ALL NO O#1TIssued br':
SOURS ULATION
Re-roofs
rgn re of Applicant/ onlractor D T of Roof
N DO M ALS DISCLOSURE Type
a� Will the appli or b 'ding occupant store or handle hazardous material
derincd by the penin Muni' al Code,Chapter 9.12,and the Health and Safety
,dC,Section 255 2(a)7 All roof: shall be inspected prior to any roofing material being installed.
❑Yes 11ro
Will the applicant or uturc building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air con rna ts as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes l No
t
I have read rdous material quircm r Cha r 6.95 of the Califor-
nia Health&Safet C ,Sections 2550.25533 34.1 un d that if the building
does not curren a tenant,tha is my risibility w orify the occupant or the
requirements mustbcmet ' rtoissu o aCcrtiff lc of Occupancy. Signatur,of Applicant Date
GGA All roof coverings to be Class'n”or better
Own r authori7.cd agent Date