08090073u0F,
4�6
cb�34a�
D U
c
b0�
Cac
–ZC
CITY OF CUPERTINO
k`£r„;k r +x '' # raT r a' `•- W,
BUILDING DIVISION PERMIT
'kCONTRAC�TORzINF Q RMATION ,
Bu1Tr4'pgpess:RZICH PL
K
BURKETT'S POOL PLASTER INC.
PERMITNO.
08090073
NEWS NAME:
PERMIT LSUE DATE
FAN JIAO
4612 CASTLE CARY LN
09/15/2008
PHONE:
SANITARY NO. CONTROL N0.
(209)529-6944
ARCHITEC IEf1GINEER:
BUILDING PERMIT INFO
'BLDG ELECT mum MECH
LICENSEDCONTRACTOR'SDECLARATION
9
Job Description
p
under
1 hacbY eflrm that 1 am ft B under d Nof ns of Ch . (my tic c i3
Dirision3afde Business and Profmssions Cme.aalmylicenev
EXT SWMPOOL MDFCTN INC LD EQUI PMNT RELOCTN, NEW
inuSmtceanuf ofra
infullam effect / �1
Licene CI fY.g /
PLMB, PLSTR, TILE, COPING; DEMO EXTNG CONCRT& REPLC
a
Dam `=1�x}PARcxrrEcis DDEcuaanon
NEW STMPED CONCRT
I undo wand my plans != d u public m, orb
Licensed Professional
OWNE BUILDER DG
the
I hmam affirm Ibal I em CLLR dNm Iht far the
My ty
Banned, and fusionLla/a :
sions Cade: My city m county
in
following reason (Saito 8rimin
which requires • permit to cnnslmcL alcor, hnpmn, demolish, ver Rpoir any suuLwm
1,she,ve, d
Prior to is inumc.. also R, toms the applicant for such permit to Ilk a Signed AuCcren1
this W is licensed to de of ON Contractor's Liccnm Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant previsions
fcomm acing with Seedem ]DOD) Of Division 3 of IW Business ane Profusions Cade) in
$35000
Nat he is eempt NeRfmm and the basin for we allgcd eamnptinn Any viOlautn of
section 7031.5 by any, applicants far a permit subjects the appliCanl to a Civil Penalty OfNumber
36206038.tol?,N
Occupancy T
not mos than fin hundred dollars (5500).
Pane Y YPe
❑ 1, u owner of the thepary. my wish wagn t Ne'v sole mmPcnsatines
of banned
r al don ad, s (Sm. ]0an Husinm
will do r the workm... arta. The, cldm h we. LiMme Law
and Professions Cmc: Tile Conuactoh License Law does rot apply lf •e owner of
_ Required Inspections
p ork through by
a impm sch reem.improvements
,
psis
mr.flefm
umploycesainywho
ve ents menu On, for nte.4
Pwneer. tym,P wttae not On,
Nauuehed,6
buwevv. the buffs id Ofdmpkiiad the towner
in gor o mid widtin Wilda
FmAnls hompledf r
et
Wilder will tun the buNun of poHnB dist W did Inst Wild or impmn (a purpose of
live Imilm
sale.).
[:) 1. as mwrcr a the property, me eaeludnlY contracting with licensed movants in
Construct the Project (See. 7D4a, Business am Professions cmc) The Cmvactor's Li-
.
cone law does not apply to an oma of pmpeny who W ilb or improves themon, and
who contracts for such pmjccu with a contractor(s) become! pursuant to the Convacm8
Lacerum law.
❑ lamtatripsundu See .BAPCfuthisrrsmt
ner Dam
WORKERS COMPENSATION DECLARATION
I busby aflino under penally of pujury ons of the following declarations:
❑ I hsn and ofComLnuo Workman -
for
Scam
mtion, for by Section
fPe Section 3'!00 of the Labor Code, for the performance Of de
ode. N ce of
r whicProvided Or mi
work far which this Permit Is ivied
N[jLjaveatd will maintain Workers Compensation b aumace, an me,fired by Section
3700 of the Iahm Code. for Ne Perfarmmee Of the work for which mit permit is issued
'
PPutt�� art:
My Workers Cmmpemation Inmtarcc curia ad,,+
Its
i
cmier: be?r• f7F INOL(C�Q.I/Im1hCy Nd.:'�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThissuUm reed rot W considered if the Permit is forarchummd drifts ($100)
or IM)
I certify that in the Performance of the work for which this Permit a Luted, I shall nor
employ any Permit in my manner so as to become subject retie Worwris Compereemen
Laws of California. Date
APPlicanl
NOTICE TO APPLICANT. If, after making this Ccnifiea c of Exemption. Woo should
become subject to the Worker's Compensation provisions of IN labor, Cmc, you mud
forthwith comply with such Pmvimins Or this penitis shall W deemed rooked.
coNSTRUCnON LENDING AGENCY
I hereby affirm that Nem is a consmsetion lending sgercy for the Performance of
the work for which this Permit a Luded (See. 3097, Civ. C.)
Lenders Name
L co dein Address
I certify that 1 have Rad this applievion am site was do ninon information is
CO=L I agora M comply with all city and county mdinarcu am stale laws slating to
Wilding cuwtetion, and hereby mmorire repmseeutins of thv City to entorupnn the
ahove.mmu pmpeny for teaRNtt Puryoes
(We) agree to eve. indemnify and keep harmlet the City of Cupertino against
tie gm may in any wyaccrue agsinu said City
cooma,jmgmmnU,canuandof Fowhtch
of of
A
APPLICANT RSTAN
APPLICANT UN ERSTAN NO WILL COMPLY WITH ALL NON -POINT
O WILL
Issued by: Date
SOURCE R TIO
/
Re -roofs
Signature 1' onlssetor Da¢
US MATERIALS DISCLOSURE
Type of Roof
III the apps' Iorfuture Wilding decupmtatom orlundlehavallowmternal
as dcMm by IN Cupenim Municipal Cale. Chapter 9.12, and the Hcalth and Safely
Ir. Senate 25532(.)]
OYu ONo
All roofs shall be inspected prior to any roofing material being installed.
Will tic Wilding taeequipmentordManawhich
If a roof is installed without first obtainingan inspection, I agree to remove
P
eir commtorfuture
Bl
by
q�nhdallous air contaminsnu u defined by tate Bay Alia Air Quality Management
all new materials for inspection.
.
❑Yu ONO
I have mol the h sum ours ucrialsmquimm ew umkr Chipwrd.95fthe Giifor.
nuttiest "IS""YC c,5muens Or.25533 am 25534.1 unduattl tht if the Wilding
Cilia nm Lormoth Fa4mMl I u my Rapmosmillty to notify to PL'omant Of to
requimmcnuw muss hem o toituance efa Cenifream Of Ocmpanry.
�— 1?, 16 _
—idthmvad.gc9
Signature of Applicant Date
All roof coverings to be Class'A!v or better
l3w;rcr Dam I_