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CONTRACTOR INFORMATION"''
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
DEVCON CONSTRUCTION INC
PERMIN905020091
ER'SNAME:
PERMITLSSUEDATE
THE FORUM
ONE:
SANITARY NO. CONTROL NO.
(408)942-8200
ARCHITECfIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S
Job Description
of CON
under Chapter 9 (commencing
1 heathy affirm that I am lune,
p
Bi and
with Seccon ]pIU) of Division 3 of Nc eusincss end Profcuium Code, and my license is
Prauns th
in fail remotion erfea 3,741/015
ADD 1322'FOR FIT. CTR/REMODEL POOL
Lima Clay Lic. g
Co.,
ARCHI=pSDECLAR TI N
1 understood my plaits shall W used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
Ihereby
Law for thefollow
Out 11. <Bempsfrom the Crtions
1C'1f 1, Ir+Icy
Any
.(&c iolh Co dc: Anycity or county
Code:
andve.
�1!� II
which w
whichingrccwaurell torIJommt,aimr. de
requires a permit u+cnnnrvn, eller. improve. any ewemmgoonnn
such e a sir
h Permit t
prior bd its issuance, alsu reto Out tW applicant for such permit to ice s signed statement
its
that umnacuw(Chapter
Sq. Ft. Floor Are
Va nation
(commencing
(commencing with Scnion]000)of Division) of the Business and Profcuinns Crude)
e)or
Out to u exempt therefrom and the basis for me alleged eumpcon. Any violation of
3 PI41DtmeOeeu
ane
Occupancy Type
Sector, 7031.5 by any applicant for a permit subjects me applicant to. civil penalty Of
not more Nan firs hundred dollars ($5(10).
I , l
s
❑ 1, sa Owner of the car employees
rf..eaulh. (See. compensation
t . _. 'Required-Ifispec[ions
will Outsma .
Ncwork. ands. swnum is hors Laded Or Offend forot
Phdo
and Curie: The law dors not apply 1f an owner or
apply us an owner
ves dommrs rid who
Prey who suchicon,andents dwiswh work himselror Waugh his
em woo milds ored
that such improvements art not eaMcd woRrnd for
own employers. that
own
divided
however, the building u hath owner-
improvementproving did one year or
for Ncpose
improv of
builder will have Nc burden of proving Nat W did not build or improv for purpose Of
bu a
sale.).
❑ 1, as Owner of the progeny, am eaclusively contracting with limned contracmn to
construct the Pri (Sec. 7014, Business and Professions Code) no Contractor's Li-
ecnu Law docs not apply to an Owner of propeny who Wilds or improves thereon. and
who contracts for such projecu with a contractor(a) licensed pars urn on Ne Contractor's
License law.
❑ 1 am aempl under Sec. . B & P C for mist reason
'
er Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally Of perjury one of the following declarations:
❑ Itomand will mainuinaCenifiam Of Consent xl4i,uurt for Workers Compere
union. u provided for by Seedon 3]00 of the Labor Code. for the Performance of Um
work for which this permit is issued.
❑ 1 nave and will maintain Workers Compensation Insurance, u required by Section
3]00 of the Labor Come, for ate performance of Ne work for which this permit is issued.
My My,Compensation Instunnm carie, and %licy number ah:
Cartier. LZTf1Ti1��+ Policy No.: tic 297goS 0
CERT FI OF EXEMMON FROM WORKERS'
�CQMPEtJSAµ71�yp,
4NISURANCE
QTis section need not h1 cCum�pfetedllthe pegrmit is rnrone nanamd Annan Ig ITA))
or less.)
I Certify that in the performance of the work for which Nis permit is isswd. I atoll nm
employ any person in any manwrha as m become subject o the Workers'Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cenificaa Of Eaemption, you should
become subject to the workers Compensation previsions of the IaWr Code. you most
forthwith comply with such provisions or this Permit shall W dimmed revalued.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Item is a construction lending agency ror me performance of
Jr. work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lende6 Address
1 ccnify that 1 have read this application and sum that the above information is
Curren. 1 agree 10 comply with all city and county oNinances and slate laws rchum, to
Wilding construction, and hereby auNanne reprcun ativa of this city to carer upon the
above-mentiuned Progeny for impccdon purpoma.
(We) agree IO save, indemnify and keep Interim she City Of Cupertino against
IiabiliUu.judgments.emes and eapauea which may in any way accrue agams swid City
in comeywnce of she granting or this permit. r
APPLICANT UNDERS1 NOS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULA
/ADate
Re -roofs
Type of Roof
Signature o(Applic onuuto
HAZARDO S MATERIALS DISCLOSURE
Will Nc applicant or fuwm building occupant tore or houlm haardous material
u defined by the Cupertino Municipal Code, Chapter 9.12, and W Nesbit and Safety
e, Smile. 25532(.)? 1'
❑Yet yQnu
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will thea applicant ter/fuw\rc building occupant nate equipment or levee: wnlan
pp s P yuipmen
cmil mmrdnus air mmarmnanu u defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
�Nu
❑ Yes
1 have mad the hvaNnus maalull ho uimmenu under Chapar 6.95Of the Caliror.
nu HralN& Safety Cock, Se does 25505,255]] and 25534. Immeramnd theriDhc Wilding
dors not currently haus a aunt, Nm it is my responsibility m richly Ula w<upanl of IW
rcyviremcnts whichm bemetp rm ,nt«nracerunrateoroccepany.
Signature of Applicant Date
✓'�` ei-lB-oS
All roof coverings to be Class "B" or better
Ownerrmiliagent
Date