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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTORIF ORMATiON h
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BuDINGADORFss:
PACIFIC POOLS
1ERMITN0.05070168
OWNER'S NAME: l
PERMIT ISSUE DATE
E:
SANITARY NO. CONTROL NO.
(408)377-5224
ARCHIIECr ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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p LICENSED CONTRACTOR'S DECLARATION
m Job Description
p
u under provisions of Chapter 9 (commencing
1 hereby atr ' thea 1 am If Me Business
with Section by &f of Mat In 3 of en ed n de and Pmfesnof hat 9d o licence is
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m full tons ands,pet. 5'l��l
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OOL AND SPA
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ARCHITECTS DECLARATION
I undermnd my elWl bo used u rtcoNs
MAy
it �- 2005
puts public
�a Licensed Professional
DECLARATION
3 Oat
I am exempt from
53 I boreny affirm that I am exempt from Ne Contractor's License Law for the
o following resume. (Section 703 1.5, Business and Pref esions Cade: Any city m county
�i which requires a permit be construct, all., improve, demolish, or ¢pair any elmcmre
$230000BUILDING
m prior to its issuance. also requires Me applicant for such permit to Ne a signed mtement
< Commuclor's License Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed puraware to Me provisions of the (Chapter
$ (eomenncing wiLh Smdon 70DD) of Division 3 orthe Businaeend ftfmiou Code)or
.. that Im ns exempt therefrom and the basis for the alleged exemption. Any violators of
WF6eirTU
Occupancy Type
Section 7031.5 by Any applicant for a permit subjects the applicant to a civil penalty of
not ¢ort than five hundred dollars ($500).
❑ Lasownerof the wpleyw wlthwae Neu ale compenadan,
Required Inspections
Me suny,ormy
Peak
retapplyasin, Business
will dothework,and e
and Profusions Cade: The Conmcmra License {new dols
e:TheOrebaalomndedoraw does apply u an owner of
q p
or his
who buildsviimprowthereon.andwho dacesuntwork
omse1fart frueh
am
own employees, provided malsuch improvementstase not Tended moffamedcdon,
Me owner-
Nebuildingart improvement is sold oft year ofaepleforNeowar-
Wilderhowever.
did
buildtt will Mw Bre Wrdcn of proving Wm he did at build or Improve for purpose of
asuJ.
❑ I, as awns, of the Property, am exclusively contracting with licensed aaumrs to
construct the project (Sec, 70UL Business and Profeadons Cade:) The ContracmYs Ib
cents taw does not apply m an owner of property who Wilds or impmvts theman, and ,
who convects for such pmjecu with a anuacear(s) licensed pmaunt u the Contractor's
License Lew.
O l A. exempt under sec, .B&PC for this mason
O. Dau
WORKERS COMPENSATION DECLARATION
I hereby of low under penalty of perjury one of the following declarations:
01
have and will ¢mown a Cenincamof CaneenuoselFinsum fm WodmesCompcn-
nation, as provided for by Semis 3700 of the labor Code. fm the performance of the
work for which this permit is wood.
❑ 1 have and will maintain Worker's Compensation Worma. u required by Section
3700 of the labor Code, for the performance of Me work for which this Ferretti issued.
My Warkeess, c �due Immrat`n�a arta. and Policy number m:
Carrier: SAM'S PolicyNt.:l f 6 9129 2-0 a
CERTIFICATE OF EXEMPTION FROM WORKERS'
1 COMPENSATION INSURANCE
(Thu secda and notbecmnpkud Uthe permit ufarona hundred dollen (SIM)
or sea.)
1 certify Net In the perfamaac of the work for which this Permit Is isnmd, I shall not
employ any parent in try manner an as u become subject to tiro Workeri Compensada
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exception, you should
become subject to tho Workers Communion provisions of Ne Labor Code, you most
forthwith comply with such pro,um. art this Permit Mall bo doomed revoked.
O
CONSTRUCTION LENDING AGENCY
4
I hereby affirm that Mere is. mnu uctim lending agency, for use Performance of
7 the work for which this permit u issued (Sec. 3091. Civ, C.)
'
QLender's Name
,
Lender's Addmts
z
Q 1 cerdfy that I low read this application and mm that the above information u
correct. l agree to comply with JI city and county ordinances and mm laws mining to
building construction, and hereby authorise representatives of We city to cm er upon Me
abovementiaad property for inspection purposes.
(We) agree to aro, Indemnify and keep hamlets the City of Cupertino against
y lubllidu,Judgrants.c m and expenses, which may in anyway aeesa against said City
In consegana of the ranting of this pemiL
APPLICANT UND STANDS AND WILL COMPLY WI A L NON -POINT
Issued by: Date ( v
SOUM REGULA NS.
Re -roofs
Type of Roof
Sigumrt of APPli for1. Date
HAZA OUS MATERIALSDISCLOSURE
Will Me applicant or future building =upset atone orharalle hoommus maudal
as dented by the Cupertino Municipal Code, Cleapter 9.13, and Me Health and Safety
code, SnedYmon 7.5532(07
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will Me applicant or future building occupant use equipment or devices which
it hazardous air connotations u darned by the Bay Area Air QuWty Management
all new materials for inspection.
District?
❑Yes
I have read Nehu� mammals requircmcnu underCMPmr G95af du Celifom
nu HcalM&Saf.y Cade, 'oro 25505.25533 and7353d.I undenund Mattime Wilding
does not currently hoc a knum. Met it u my responsibility to no occupant of Mc
requirements which must met In iswance ofaCcninam OC c
Signature of Applicant Date
Cl IU
All roof coverings to be Class "B" or better
owner anuthomcd Igen Dow