03080126 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 4CONTRACTORINF.110RMATION
BUILDING ADDRESS: PERMIT N0.03080126 3080126
'R'S NAME: PERMIT ISSUE DATE
NE: SANITARY N0. CONTROL N0.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
I o LICENSED CONTRAC OR'S DECLARATION
i 8 0I hereby affirm that 1 Bm flam (com
ed under provisions of Chapter 9 mcntlng IOb Description
with Sudan 70(1 Division 3 of the B.m.and Profeaioal Code.and my lice..is
isfallfalm enseClaere" Lic.g DEMO SWIMMING POOL
jNZ L
eN Dam Contractor
`q ARCHITECTS DECLARATION
e 22 I understand my plans shall M used as public records
0 t, Licensed Professional
3 OWNER-BUILDER DECLARATION
y 1 hereby affirm that 1 am exempt farm the Contractor's License Lew for the following meson.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit ,,cnnsuuct.alter,improve,demnfsh,fir repair any nrucm. yX7 ,
Prior m its issuance.elan requires the applicant for such permit to file.Signed Statement
p_pZsQ
that he is licensed pur.anl to the previsions of to Comracwr'e Lice..law(Chapter 9 YJ F r Tea alDattOn
d I•
(commencing comencing with Section 7000)of Division 3n1 the liusimartud Pmlcawas Cadc)or -
x S$E that he Is exempt Underarm and the basis for the alleged exemption.Any violation of 3692
Semon 7033.5 by Any applicant for a permit,nbiem tate appEaal t to a Civil penalty of APN Number Occupancy Type
not mom man five hundred dollars(M).
❑1,as owner of the property,or my employees with wages u their sale compensation,
will do the work end meewnum is not intended m.ffied formal.(Sec.7094,Buslrmu 704 _
and Profession'Chile:The Convector's Liceme Law deal not apply m an owner of Required Inspections
progeny wit builds or improves memon,andwho daessuchwork himself ser Waugh his
own employees,provided thauuch improvements ate not intended oroncmd far to.If,
however,the building or improvement Is mid within one year of completion,the Owner. '
builder will have the burden of proving mal he did at build or Improve for purpose or
sale.).
1,u owner of the patient•am exclusively contracting with demand cmnvanors to
contract the pmjccl(Sec.7094,Business and Professions Cade:)The Contractor's Lb
cense Lew docs not apply m an owner of progeny who builds of improves vemon,end
who convects for such projects with a conuactur(s)Ilansid pursuant.the Contractor's
License law.
❑f... niumarSee. .BkPC( ma o
!9P. s Dam r e�n
W 'S COMPENSATION DECL.ARA
I herby affirm under pealty of perjury one of the following dechinaka c
I have and will maintain aCenineate,of Consent to self-imum for WorhfsConpcm
avian,
as provided for by Section 37M of the Labor Code,for me performance of the,
work far which this rental is issued.
0 1 have and will maintain Worker's Compensation Insurance,at ne,imd by Section
37W of the labor Cade,for the performance of the work for which this permit is issued.
My Worker',Compensation Insurance artier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section wed not the compkaid if the permit is forma hundmddrelan($1010
w ICSL)
I certify on,in the perfnrmmee of One work for which this permit is island.I shall net
employ..,person army manwr.as to baceme.bj.,to than Wort iComrewtimi
Law,of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become object to the Worker's Compensation provisions of me Lahr Code,you mull
.J O forthwith comply with such Provisions at this Permit shall h dcemcd divided.
zr~N CONSTRUCTION LENDING AGENCY
Fr Ihereby afro.metclanal..confined..lending agency far the p nfmmanec of
IY > the work for which this permit i,issued(Sec.3097,Civ.C.)
Q Isodch a
Nema
7 Z Lunde;,Addm
V O 1 ceNfy that I have read this application and sum met the.hove information is
V. F correct.I agree to comply with all city ad county ordinances and sum laws milting to
V building construction,and hereby amhorim representatives of this city to cnmrupon me
[s7 ahove•mc sioned property for inspection purposes.
W (We)agree to ave,indemnify and keep hermlm the City of Cupcnino against11
,.y rvp liabilities,judgments,costs and expenses which may in any way accme against said City
OZ in coesegwnce of the granting of this Permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY —NOJ POINT Issued by: Date
3ysU�TH/ALL
SOUR EGU TIONS. O /�/
Re-roofs
Si ewre of Appli ammeter Oem
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applica 'or f ttme building uaupmi Stora or handle houdous material
darned by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
.Seeman 25532(.)? All roofs shall be inspected prior to an roofing material bei. Installed.
Yes P P Y 8 8
Will me 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 haardous air contaminated;a dented by vat Bey Area Air Quality Management all new materials for inspection.
unlet?
❑Yes Nu
I have mail W hasrdous materials requirements under Chapter h.95 of the Califor.
nia Hulth&SarelyCe4,Sccuau255(15,25533u U534.Iundcnund Wheal.Wilding
does not urently he.a emit mm it a my dispoesmilh,in nodl'y t upam.
mgnim rah wlhemetPaidtoissumccof.Ceniicam Signature of Applicant Date
or ewhotirc e t Da. All roof coverings to be Class„Bat or better