00090183 CinuCPERINO IT CONTRACTOR INFORMATION:to DVPERM
BU ND ft[ 5SA: PER.MR;gO.
�TLVES DR ',. .;,00090183
MEN S CHRISTIAN ASSOC F AP019 /29/2000
NONE: SANITARY NO: CONTROL NO.
Jar ARCNITELT/ENr'INEER 'BUILDING PERMIT INFO
❑ BLDG ELECT PLUMB MECH
[ z „ rl ttek LICENSEDCONTRA(TORS DECIARATION'f _ " v']ob�Description" '- -
JZ 11 by'afi nrhatl ml' sedu do p rt temps 91om dng POOL SLIDE P
I- x im Sccuon70W)ofDvmon 3ofthe Bu eland Pm4as ons Cnde.and ny teen¢
isinfulifrmandtffind, Fad,® / LF.93 _
z a Llcensc Class Lid.k .tT°N p
y LL N Dat[ Comracmr .
r.a.3} ARCHITECT'S DECLARATION AUG a 2002
° 1 undaatvnd mY Dlum nM1nll M1c axed as public rcrod,
do O Licensed Prom,,adeal
i OWNER-BUILDER DECLARATION
1 hereby alirtm that I um exempt from the Conlranar's License Law for the �u��pO�G $o
F¢ following reason.(Section 7031.5.Business and Professions Cade:Any cal,or county
E s D which requires a permit to construct,alter,improve,tlmnollsh,or repair any swcmrc
ca3 prior to is issuarrace,also"ifire,the applicant for such permit to fk a.ged statement
lbatheiii,limmodpwaitat lothe"provisionsofthcCmt=toesLicena,La (Chap¢r9 v ' e,)3 y,rjE�!Y�,'tl�,c•` .,_t Valuation
(commencingwith Section 00
71 of D' on 3 of the Business d Promv,ion,Codd
or that Ira is eumpt tberefouh and the basis for the alleged e,empnom.Any violation '
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty.
Lap W,rawre dem five nonmed dollars(SSW), 10- A�ipp'thjlgZ' Occupancy Type
❑Las awnrofine prhltery,at myeltdoyeeswhh wages as alelrsale rompemiumar 104 - REBAR' . . • . .
will ne the warp,and Professions
structure is not intended s tar a Law for snot(Secapply to 4.
an 10 7 - POOL/BOK&iLNQ Inspections'' ,`t a, -.
'ownrBusiness and exty Won
Cade:The Contii menr's.add w Law does h apply m an
owner ugh his
wlm bayed,ar;mpra l t mereahiand ere does such work himself 3 0l - ROUGH PLUMBING
\, or through hs own employees,provided that such improvements meol arc not intended or
offered For xthe:ILhbweve9 mel have rix sold he did one " - --.... .304__.__. ROUGH ELECTRICAL
.. ._. .. __
Wilding or improvement year of _
mproveiomv�cw"ide1r will have me burden of proving that he and hrn bald or 502 - FINAL PLUMBING ENERGY
D1.a:o�a:or the pdipemy:am exclusively contracting wirolicensed contractors toe: .. 503-' -- FINAL 'MECHANICAL `ENERGY:..•,- _ ..
construct the project(Sed.76 ,Business and Professions Code:)The Camaro:s 506 - GAS TEST
License Law does not apply to an owner of property no holds or improves thereon,
and who eoagdcts for such m 3 u nn tmetw(2 1<used p y.in to the .. . 51.0=- FINAL- .PLANNING -. " ` y;y-•
Cdnmd t r s_deen,La 4' j s. _ t r __-
IDIamexamplundersec.i B&PC fon hisreamn 511 — 'FINAL 'POOL"' '••"` -
owner Date 516 — FINAL BUILDING
WORKER'S COMPENSATION DECLARATION
_ ) I hereby af(sin antler penally of pe j.,one all following declarations:
7 1 irmati n,willprovided
a Cby Sembf Cart37W o m xLabor far worker's.
'ompensave a,provided for by Beckon PW of me Labor Code, for the
perfomuna orthc work Tar which his permit is isswed L .. .
D 1 have and will maintain Worker's Compensalioa Insurance,as required by Section
370 of the Labor:Cade,for Ne performance,of the walk for which this Permit is.
issued My Workers Compsnaaion Insurance carrier and Policy numberaxr
\n -. .. ...-... •.
«:o
Cvncr• I l � ...°•" Policy No .--_
-f v.ifsCERTIFICATION OF EXEMPTION FROM WORKERS s . .' ; ss..if.. i� d C t.;'t,°i
COMPENSATION INSURANCE'-
'I" dbis senian need not he completed if she prnnit is for one hundred dolian -
.. ISIW)mlessd , - .,. .. it-n.s•f.. ,.`.,
.....-.,.._ .a. .
I '1 1 nnplo that m ins peefortnanee of me work for which al pc-t erred,l ri •: . ._ __
hall nal employ any person in anymanner so as or becomsubjectm ers
become subject the Work ' '
Compensation Laws of California..ie.Dine'
Appli
NOTICE
nt
N _
OTICE TO APPLICANT.Workers
co compensation
p visi Certificate o of Labor ode.you mind "
becomeau comply it Workers Comnemaaon provisions of the Labor Coda you must
Z Q' 'fonnwial comply wish such provisions or this permit shall M decmM re.liked.
CONSTRUCTION LENDING AGENCY
> affiran
a > 1 lairebywhich that ale aconstipationleading s.C I forme performance
F.r oftheark fo h h m permit -sued(Sec.3097 C' C)
0. G LendersNam- ....
z: .LendereAdd e., M1.. tsi I•�s,i,.�
I degree that I have read this ity.anatton and sins that the above information mion is
U correct.I con to comply with all city and county ordinances and sate laws relining
:0 4.) to building construction;and hereby emhdooa representatives of this city to coal upon \
"Gil me above memdned P-aP'aY for.inspcnion purpoas.•
,� d 'IWdagree msave.aldemnify and keep harmless me City of Cupertino against,
rn liabibtics,judgments,costs and eape.,a,which may in any way accrue against said -
u rZ+ City in consequence of'
f the granting of is permit.
i APPLICANT UNDERSTANDS'AND WILL COMPLY WITH ALL NON-POINT �-
souRCE'RecuLAnorvs. Issued by: Date
Signature of Appe<andUrnmemrDate Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE' ' 'I
as deGnW by thaPPlicamaruuve Wilding occuWit store or handle hauNaus matvild Type of Roof.:
W II Ire -..., t:...-...
e Calen Municipal Cod Chapter 9.12.and th Hcahh and Safety - - - -- --
'Code S0Ycclmn Z512(a) R 1•• r s , - f"('IY Y y r ,l .. ,y
_-_Al] roofs shall be inspected prior to any,roofing.material being installed._
Will m applicant future building occupant equipment li devices ar h' If a roof is installed without first obtaining an inspecttori-I agree to remove
emit a
hardaus an chin m t -defined by al Bay Area Quality rM'es which
m
District? , ❑No all.new materials for inspection._
nspection_'Applicant understands and will comply with
all non-point source fegulattons.-. - °- - " ,_
1 have read me haddardous materials eegmremcros under.Chapter 695 of me
Cd;femia Heallh&Safety Cade,Sections 25505,25533 ad 25534,1 understand ma
ifinebiildiagdoa,mucirremlyhaveamnanC that itismyresponsibilitymnmifythc - -• - - - .. .__
"occupant of the dequiremena which must be met prior to issuance of a Certificate of
aoaprday.,
Signature of Applicant _ Date _
ow^qct aomoqud agent,•' Date All roof coverings to be Class "B"or better
i
f Y( r I .I r'` ,; "..• .. - _. . OFFICE