04080025CITY OF CUPERTINO
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°+Ci1NTRACT®RyINk'ORMATION
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
LEWIS POOLS _
PER""04080025
ER'S NAME:
PERMIT ISSUE DATE
KEITH B
SNE:
(408)371-6690
SANITARY CNTROL NO.
ARCHMICTMNGINEER:
BUILDING PERMIT INFO
•
BLDG ELECr PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm Net 1 am IiLenxd under roviaiom of Ch.ptec 9 (commencing
wiihS 1IXq)uf Dio aT iNe Burin Pmo, ticµ Ocarmylice.,IA
ire len anddlrtet. ,v// lY
Lice LI N
SWIMMING POOL
Dart Carlrattor
A Nr1ECl'S DELLA 9
ss
�'�/e�
.,Col. J my plans shill be tied u Pu ¢ ¢cards
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APR �� 2005
Licensed Pmfemmi.mel
OWNER-BUILDER DECLARATION
I lerthy affirm 11. exempt Plum Be feanlrnel ors Law fou LIC
Any
: C
following moon.(anis(Simeon 703 Const5, Business and improve. derinns Code: Any city or county
Which
which rtaua palest im conatme altec, improrc. ri repair any xOUCIUMmment
� �A �.
issuance. h Permit t
priormslcenseprsuant the IM applicant for sucContractor's
p Zh {�Valuatlon
F[. Floor Area cif
that to o
of theeeBusinss License Law ChapterCook)
totheof
Sq. it
tl '`f
mencttnxdpuuvant
Croon of
Division at
of Division 3 of
e. ng tt exempt And Proon.
fl �•'
A.,nm
that he u exempt therefrom and the buss fm de Alleged exemption. Any violation of
Me, he Us erefourn And the Al eged
32 �A.rawni.,i. a.
'�CrOO Occupancy Type
e applicoaciind Penalty of
Section 1031.5 by any applicant for A permit subjecm Nanu
not mart Nan five handled dollars (5500).
1, As owner of the pmpwy, or my employee with wages As their sole compensation,
Required Inspections
will do the work and the someone is not intended or named for salt (Sec. 1094. Business
And Professions Cndc: The Conuacmrs License Law doe not apply to an owner of
pmpeny who buildsor improver thereon, and who doessuch work himself at through his
ten employee, provided that such improvements art not intended oroRered for sale. If.
however, Ne building or improvement is said within atm year of completion, the owmer-
huilder will have the burden of proving Nat he did not build or improve for purifies, of
rated.
ch rte ownec of Ne pmpert , am exclusively Contracting with IiceruW contractors to
ole act the project (Sec. 7044. Business and Profusions Code:) Tse Cantaactur'a U.
cense Law doe not apply to an owner of property who builds or improves thereon, and.
who Cannncu lar such mays. with a c.rummeor(s) licenxd minumat M the CoAnomMes
Lice ae La-
0 I Am exempt under Sec. , B ds P C fm mi, ..an
el Data
WORKER'S COMPENSATION DECLARATION
I hereby aRtm under penally of perjury one of the following dielantions:
-
1 haw and will maintain a Cenificmm of Consent to felt-insure for WorkcesCompen-
And.r, u provided far by Section 37M of the Labor Code, far the peffortna.m of the
work for which this permit is issued.
I have and will maintain Workers Compensation Insurana, u required by Section
3100 of Ne Labor Cade, for Ne performance or Ne work for which this permit is issued.
My Workeri Compensation Insurance carrier and Policy number am:
C mer. No.:
CERTIFICATE OF EXEM FROM WORKERS'
COMP ATON INSURANCE
miisaccumi need.., W Icted time Permit is Income hundred data. (SIM)
of mss.)
t
1 cenify Nm in the perfla a u c work for which Nis s,.I-d, shell nut
cmPloyanyperso any c azo a bjec Workeri Cnmpensa,lon
tows of
Applica t
4%11Cfy T PLICANT: If, after making this Ccuricate of Exemption, YOU annual
subject to the Worker's Compeumion provisions of the LAW, Wr Cod. you muv
forMoith comply with such provisions or this permit shall be deemed revoked.
CDNSTRURIDN LENDING AGENCY
1 nanny thi Nes them is a construction 3 n lending genet' Inc the Performance of
which
Me work fur which rho permit is isiucd (SCC. 3(19], Civ. C.)
r
Lender's Name
lender's Address
j 1 cutify I harc read Nis application and sum Nat Ne ebove information is
' corrttk 1 tog to a ply with all city and county. inatmes and rule laws totaling to
buiidingco wcim. and hereby Authorize representatives of this city m enter upon Ne
1 ahovemem nedp pent' far demnify An lace, es
s, cossnndexpc.xa which may in any way eccrvc against said City
j (a,j. agree o save, indemnify and kith harmless tiro City n Cupertino id City
inConsequu ingot n it.
APPLI Consequent, UNDERMcgranSTANDS
' APPLICA UNDERSTANDS ND ILL COMPLY WITH ALL NON-POINT
Issued by: Date 6/1
SOURCE GULATI e_ � v./
r 6
Re-roofs
Type of Roof
Dem
ammo ApplicaHAZARDO
HAZARDOUS MATERIALS DISCLOSURE
Will Nee or nature Wilding occupant stoic m hatWk hazardous l
Calci
ematand Safer
dcrined by the Cupeninn Municipal Code. Chapter 9.12. and the Health and Safety
c. Section 25532(a)? 1
All roofs shall be inspected prior to any roofing material being installed.
Ve 4>," o
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will Ne aMith am or Boom building Occupant use equipment or device which
mit hxzadd iir c monomania As Jcfncd by Me Bay Area Air Quality Management
all new materials for inspection.
District] 1 u
❑Ys
I hav ad c hazsrdnus materials requirements under Chapter 6.95ofMeCmirm-
niaHcalth&S Codc.Secdons2550. 3am125534.1 undcrsmntl thmif the Wilding
does not Corte y have Atenant. Nn t' is my sp mairlity w fairly the..'arrt or de
mquiremc whchmuxbemtpdu nils eofaCertificate OfOC ...y.
Signature ofApplicant Dale
All roof coverings to be Class "B" or better
caner m authorized agent Da¢