01040149 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDIIESS: PERMIT NO.
1103 ELMSFORD DR SWAN POOLS 01040149
OWNFR'S NAMI?: APPLICATION SUB DAM
SILVERMAN, RICK 8 MARY t495 S" ' WINCHESTER E V ' 04✓26/2001
�I PHONF. SANITARY NO. CONT BUT.NO.
(408) 866-6893
O O ARLIII'I'[CUFNGINEER: ' BUILDING PERMIT INFO
�E+ BLDG ELECT PLUMB MECH/
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LICENSED CONTRACTOR'S DECLARATION Job Description
m� I heron IHnn,ha I am licensed MnJer i on>of Chat 9(rnmmcncin
p�=' Ya pow si per g —
F'3Cm with Smaion7lXXp,fDlvid nJof,he HMsmcan:uaA Profcxsions Code.undm licemm
fix» in haliduarce 3 SWIMMLNG POOL.
E:.�'a Licen¢Class Lic.p I IC
3 h Uam 8_�_( Sommctor�
0
ARC]II'l lI d,dl)ECLAI ION �r
E LL O S 1 understand my plans shall be uxJ as public mcordx
E�N
e. p 5p Licanwd Prnline. .nionW Jut
20 I here.affirm that 1 1. exempt from the Contractor's License law for me 1 9
C a following mason(Section)NLS,Rosiness and os.dhaaal C,or Any city naeur ne, G
O Which mtsissune.also
re amanhealter. for such permit
Bre a signed
ig on,tuement
W that hor n sfiv issuance.ab ant to rhe that applicantnofor Coop aien License gne(Chaps ant
mane criarnnNpunh." 'hofhe Emissionsofthe it,Busier%Licensee Lse awn,, ode) S Ft. Floor Area Valuation
or that he I,exempt with Section i..I and a baton.of the Bmloess:md Pndan,vi Aide) q' ,
drat he a b .,I,apon and me Examit thm,dlaged mxetmptiatt.any violation - $254417)
of section 7031.5 by any drol d nt for a pemnit sMnjmctn the.applicam v,a civil penalty
ornm mare man fine nnndara sonars(asro). APN Number Occupancy Type '
❑L as owner if me pct,pony.or my cmployccn with wages as their sole comfismatlon. 36206006. 00
Will do the work,and the structure is not intended or offered for sale(Sec.70TU
Business and Professions Code:The Contractors License Law dues not apply u,an Required Inspections
alov,of properly who builds or Inrpmves them I.and who does tach work himself
or through his own employees,provided that such improvarems are not intended or 103 — UFER
offered for sale.If,however,the building or improvement is sold within one year of
,rnpinaon,d,e owner-builder will have the burden el proving he,he did Bol bnild or - 104 — REBA R
impmm Ito pmp„mofnnlc.). 107 — POOL/BONDING
❑I,as owner of the progeny,am exclusively contracting with licensed contrmunvu, 301 — ROUGH F'LLItdBIPIG
Lmanrc't,he projce,N,a.7M4,Bmincsx and R'oleseiona Corel'Ilie Cu imctnr's
icense Law does not apply to an owner of property who builds or improve.,human. 304 — ROUGH ELECTRICAL
and who contracts for such projects with a c.ntmaort,)licensed pursuant to the
Co"`'1`'11`1 ucen`e Law 502 — FINAL PLUMBING ENERGY
❑1:no exernm under Soc. .it&P C for this mown
Owner Date 503 — FINAL MECHANICAL ENERGY
WOR KI;RS COM 11I7NS A]ION DSCLA RATION 506 — GAS TEST
0 Ithereby affirm under penallyolpeinryonenfherolmwin,dumamerec: 51.0 — FINAL PLANNING _
❑ I have ami will ri dmam a Cenificam of Consent n sell-i-me tar Worker. 5].1 FINAL FOOL
Contpmasaion, as.provided for by Section 37H) of the labor Code. or ,her
perarromeeofthe work tarwhich this permit is inxned. _ 516 — FINAL BUILDING .
❑1 have and will maintain Worker v Compensation Insurance,as required by Section
D7W al the Ln Cu,ll:,for,nc mt
perfaance of the Work for which,his permit is
issued.My r, rr�mnsaion ln.wmnce carrier s/d Pct'y nuns O are ... t
Carrie( Policy Nn: 3( 0
cBRriricATION OF EXEMPTION FROM WORKERS'
COMPHNSAI'ION INSURANCE
(This section need not M completed if the permit is for one hundred dollars
(sl W)err less.)
1 emify that in the perfomunee el the work for which this panni,is issued,1
shall no,employ any person in any manner m as to broom subject,o the Workc d
Compumauon Lnws of California.Dote -
Applicant
NOT ICF TO AITLICAN'C If,almr making this Cmificmm of 17 cmpti.......hould
becoe subject o)he Workers Compennat inn provision,of the lamast
.1
bor Code,you
O Qm
bod' h Comply wlh nal,pnrvixien,or mit in permshall he J,enood r'cvoked. -
z R
fA CONSTRUCTION I.17NDING AGENCY
> 1 hereby affirm that then:is a construction lending abency for We perhmmamce ,
Gs7 of the work for which thio'perml,r,,,,e,d(Set.3097.Ci,C.)
6. f] Lender's Name
= z Lender's Address
fs, O
correct.
candy that I have read his application and nue Ina the above rommutlon is
rrect.
F., I blare to comply with all dry and county ordinances and state laws mlming
to building nnaater,and hereby bahorlzc repmsemes of this city to enter upon
m .
W eahove-neematie
mionc,l IF oy far Innlx'Crm,pummel.
1.., L (We)agree to save.indemnity and keep hamnleo the City ofcupernno against
(A liabilities,judgments,coos and expenses which may in any way accede against said
U z City in cor,o nence of the graoin,of this permit.
APYI fANT UNIJERS'1'ANDS AND WILL COMPLY\YITH BLL NON-POINT
., so'R r R Gu ill(v Issued by: Date
Signarum of npplic HA7A DOU Dam Re-roots
HA]�Rnum MATERIALS DISCLOSURE
w,n me a Cupp t or rMnre Municipal Cl occupant a„m 2,and
the ba amaan material Type of Roof
as def Bed by the Cupertino Municipal Gxlc,Chapter 9.12,anA the Ilcxhh and SMlny
Cale,section 255121a); •
D Yen 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rams hdddiagtecupam„w cgn4,ttrem or devloes which If a roof is installed without first obtaining an inspection, 1 agree to remove
Boit hazardous air contaminants as defined by the Hay Area Air Quality Management P g
D,alkl?vel ❑No all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have mad the hazardous maedals resItion nus under Chapter 6.95 blithe
California HCz11h&Safely Core.Sections 25505,25533 and 25534,l understand that
Ifthm heildinl Anus not currently bum a tenant.mel it is my respansmila,to notify the
occupant in the re,rvircmems which must M met prior to issuance,of a Certificate of .
(kc tory.
I�oS CKz 'l-u-01 Signature of Applicant Date
Taxer or,aumorind,Lenr Date All roof coverings to be Class`B” or better
OFFICE