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CITY OF CUPERTINO°''�'''
DIVISION PERMIT
CONTRAC�TOR`INFORMATIQN,,
BUILDING
BUILDING ADDRESS:
LIFETIME POOLS INC
PERMIT NO
05050049
OWNER'S NAME:
PERMR MOE DATE
E:
SANITARY OLNO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby affirm that T am licensed under provisions of Chapter 9 (commencing
with Section 1071) of Division 3 of Jae Business and Pmfrssions Code, and my license is
in ren force and effect.
—� -22(9-22(9REVISION--CHG
SETBACK TO 6'
L;cenaCl Lica
DaN — Contractor
DECL
ARCNIiECsS DECLARATION
I understand my plans shall he used in public recants
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affmm that 1 am exempt from thc Comranora License Law for the
following recon. (Section 7031.5, Business and Professions Code: Any city or county
which mquims a permit to construct, alter. Improve, demolish, or repair any illuctum
prior n1 its ismance. also mquitet be applicant for such Nrmll lO file a algned iu mmenl
Ft. Floor Area
Valuation
,he, he is heensed Pastoral I.the pmviewas Of the Cofactor's Lima. Low(chapwr 9
Sq.
(commencing with Section 700(1 (if Division Sof the B usiness and Professions Cudef or
then he is esempt therefmm and Jct but far the alleged exemption. Any violation of
3 tLbetO 0
Occupancy Type
Section ]031.5 by any applicant for a permit rubjecu the applicant m a civil penally.(
not mom Nan five hundred dollars (1500).
El I, u owner of the pmpeny. or my employees with wages u their sole compensation,
Required Inspections
will do the work, and the structure is not intended or oRemd forsalc (Sec. 004,1. Business
and Professions Code: The Cuntmcmrs License Law does not apply m an owner of
property who builds or improves thereon, and who doeasuch work hireself ortimugh his
Own employees, provided that such improvement are not boarded oroRead for nue. IL
however, the building or improvement is sold within one year of completion, the owncr-
builder will have the burden of proving that to did not build .r improve for purpose of
sale.).
❑ 1, as Owner of the propeny, am asclmively contracting with licensed convectors to
conswa the pmjecl (Sec. 7064. Business and Professions Code:) The Convacmr's Li.
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conte law docs not apply he an owner of property who builds or improves themon, and
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who concoct for such project with aconmaor(s) licensed pursuam to the Convactoh
License taw.
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❑ 1 on Hemp, under Sec. . B & P C for Ns maven
Owner Data
WORKER'S COMPENSATION DECLARATION
I hemhy affirm under penalty of perjury oto of Ote following declinations:
I have and will maintain a Certificate of Consent to Ylf-insum for WorkoesComper-
safon, as provided for by Section 37M of the labor Code, for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, in required by Section
000 of the labor Code, for the performance of Ne work for which this perm;, is issued.
My Worker's Cam mmice lm trance earricr and Policy number me
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Cllrier. �% M FUND Policy,.: 010No-11P61,P2L
CERTIFICATE OF EKEMP ION FROM WORKERS'
'
COMPENSATION INSURANCE
This arclima need not hccomplmcJ if the permit is future hundred dollars ($100)
nr less.)
I ocrO N that in the performance of the work for which this permit is mord. 1 shall at
employ any person in any mannerso as In become subject to the Workers' Compensation
laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cenifieale of Exemption, you should
become subject to the Worker's Compensation previsions of the tabor Code, you most
'
forthwith comply with such provisions or this permit shall be dmmed invoked. '
CONSTRUCTION LENDING AGENCY
Iherbyaffirm be, then is. construction vgcray for the perfurnance of
.0 h,
' the work for which Nis permit is issued (Sec. 3091. Civ. CJ
tondo's Nunc
Lender's Address
1 cenify that 1 have read this application and slow that Jin above information is
' correct 1 agree to comply with all city and county ordinances and state laws relating to
building convection. and hereby authonae mpoesenutives of this city m enter upon the
shove -mentioned not for inspection purpmes.
(Wes) agree m save, indemnify and keep harmless be City of Cupertino against
j IiebiliJcs.judgmcn¢ eras and enperuer which may in my way accrue against said City
r in consequence of the ting of this permit.
APPLICANT UN ANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCERE NS.
Re -roofs
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HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Jin applicant or future building occupant 3Com or handle hazardous material
U defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safely
Section 25332(a)?
All roofs shall be inspected prior to any roofing material being installed.
6COJc.
❑Yea ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipmem.r devices which
h ha amnue air contaminant in defined by the Bay Ama Air Quality Management
all new materials for inspection.
Diaviea
❑Yes I] No
I have read the hmardsms materials requirements under Chapwr6.95 of the Califor.
nia Health& SafetyCude,Soeuou 25505.25533 am125534,1 undersand ustifNc building
does not currently have a that it u my responsibility b notify f wsupant of the
requirmmrns whichetpdor a in.arum.f. cenlfwaw or Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
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