08080241 CITY OF CUPERTINO y �t 'mo" �. e3>'s=N:ia St••'1"� - .'
BUILDING DIVISION PERNIIT TRACTOR INFORMATON,
,h-
PERMIT N0.
Bu1L13'6`tTdESS.RESTON DR LIFETIME POOLS INC 08080241
R'S NAME' (.: PERMIT ISSUE DATE
OLKEIN DOUGLAS E AND ROCK 910 SAN ANTONIO RD 09/23/2008
PHO C SANITARY NO. CONTROL NO.
(408) 738-1576
ARCHITECTTNGINEER: BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�8 LICENSED CONTRACTOR'S DECLARATION IOb Description
1 heaeby alrsnn that 1 am li¢nsed under Provisions of Chapter 9(Commencing P
with Section]ODU)of Division]of the Business and Pr
ofe
ssi
o
ns code.and my lfcrosu is IN-GROUND POOL/SPA @REAR YRD OF R-3
_Oy in full(CoandsQe '�LvNppZ
�? License Clue IJc.
r Dam G's MEC'
^� 0911 W=i DEC
2< 1 understand my Plans MWI ho nscJ as Public rtcnrda
JyU
oat; Licensed Professional
3 OWNER-exempt RDE DECLARATION
sC<f 1 homhy.turns that I I exempt from the ContracProfessors
Co :A License law for the
COC following i mn.Permit
]fnsar Business and improve.
demolish.
Or:Any city or county
S$� which requires a permit m cnnstrum,de¢improve,demaluh.m repair any stmctum
prior to its issuance.also uquiha tho applicant forsuch permit to rile a signed statemmo
< the,he is licensed pursuant to the provisions of Dc Conuactel'a Uncese Law(Clupo:r 9 Sq.Ft.Floor Area Valuation
X (commencing with Section 70DO)ofDivision JoftheBusinessrandPmfcationsCode)or 68000
E R— that he is exempt thcmfmm and the basis for the alleged exemption.Any vloladon of
Section 7031_5 by any applicant Tor a Permit mbjccu the applicant m a civil penalty of Number Occas
not re sow men fin handdollars(SIM 32637053 Occupancy Type
❑La thwerof the theseny,mmy wployces with wgnsutae'stake S". W.fluban,
will dothework,andthe an-The uuunaUnLMedorOffered s not
to a4,Budmu
ane Rofnsions code The Cont erson,License Law doh,Cot apply m rt ownm of Required Inspections
Own
property prosh;mimprovasthu prove who are
tende bimselfar Ouvugbh.
own employers,prodded that sem improvements it art net intended oronereG forsels,the Own r,,
hawser,the Wilding m iron of Mvist 4e test
within One Wild
of i m improve
a for the owrcr-
Wildcrwill have Rte Wtden of proving Nu ho did not Wild car improv for Paryou of
tele.).
1.as mvrcr of the property.tea exclusively conuuting with licensed Contramers to
constmm the protea(Sec.7041.Business and Professions Code:)M Cramscrnr's U.
cense law does not apply in an owtter of property who Wilds or improves therems,and,
who contracts for such projects with acamractot(a)licensed pucesm,in the Coneumr's
Lice.Law. '
I am exempt under See .B&PCfor this meson -
Cole
WORKER'S COMPENSATION DECLARATION
1 homhy of ire under pcsWty of perjury me of IW fallowing declarations:
❑I ham apt will msinwn•Cenifi®roof Consent m self-insure for Wahcls Compcn- .
sation,as pmvidcd for by Section 3700 of the labor Code,for the performance of the
work for which this permit u Wood
I base and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the performance ofdu work for which this Permit is issued. `/ '
My Worker's
Compensation lnsurjotx curies and Policy number au: D,�1.O l
Carrier.L/14 X4 71 f441, Policy No.;C _COS
CERTIFICATE OFEXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thu scNon recd not he completed free Permit is Intone hundred dollar(S100)
or lea.)
1 sonify the,in the pufoarnmen of de wah for which this Pa ni,is issued,l shill net
employ any person in my manner an as in become subject to the Workeri Compemauon
Laws of Califomia Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Composition provisions of the Labor Code,you menu
.,O forthwith comply with such Provisions or this Permit shall be dcemed rtvoked.
z-t CONSTRUCTION LENDING AGENCY
[-+ Ihome,affirm Wtthert u a ConstmNnn lending agency for Ute perfimsance of
L>: > the wart for which this permit Is issued(Sec.3077,Ci,C)
0 Lender's Nano .
z t<ndeex Address
U Q I Conify that I have had this application apt state that the seen information is
,T,E comes 1 agrte m comply with 01 city and county On inarcn and stale law misting is
Q`S-J: Wilding comuucdan,and Wuby sutharim roresenutives of this city on Omer upon the
[A shove-mentioned Pmpent for inspection which ms
' n, (We)agrte m an.indemnify and keep hsrmleu the City of Cupertino against
r/) in
ftheCom and es pensuabit, may in any soy umue against said City
O Z m
APPLICANT
ofthegrantingof Nu permit.
^ APPLICANT UNDERSTANDS AND WILL CObIPLY WITH A11,NON-POINT Issued by: Date '9":J,
SO/RCfa-REfgQgA�S,,
stgLLLLLL"'''//amGG//arA��aan✓Can6b//uxyarRe-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
mlltheapplicantor(mart Wildingoceupantatommhondlehua mmawred
food by the Cupeninn Municipal Code.Chapter 9.12,and the Health and Safety
.
Section z255320)?❑Y. All roofs shall be inspected prior to any roofing material being installed.
@7Ne
/ If a roof is installed without first obtainingan inspection,I agree to remove
Will ft applicant or future Wilding ompam esu equipment or Devices which P
emit haaardous air comeminanu as defined by the Bay AM Air Quality Management all new materials for inspection.
District,
❑Yes u
1 have mad the hoallonsmatedalsmquimmcnuuOD,CWper6.95 ofthe Califon
Oen HWN&Safcry Cade.Seines,25505,M533 and 25531.1 uMeraab thxtifthe Wilding
doer mat corm ty me thu m m
have• anis it my responsibility tiry the occupant or Rte
mquirem� /ntaj cb�tsat be=1 prior issuance of a CertificateCertificateancy.
of c,cupSignature of Applicant Date
Owner�ora ttharacdd agcni Date' All roof coverings to be Class'}4"or better