05100128 CITY OF CUPERTINO ' •a°•a;
BUILDING DIVISION PERMIT CON'.C.RINFUR1y1A'TH �..
'..: drr„ *ya2 nu5uas yam. .•..��s. .t.�.a
BUILDING ADDRESS: PERMIT N0.O 5100128
OWNER'S NAME: PERMIT ISSUE DATE
WITT, DAVID R.
E; SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSED CONTRACTOR'S DECLARATION JobDescri tion
i 1 hereby affirm that 1 am Hamad under proviaioes of Claim,9(commencing p
a< with Section 7000)of Division 3m`the BuslrcasW Professions Cadc.and my license is
in fall farce And affect. PARTIAL INGROUND SWIM—SPA, 7 X 14 FT.
IgE License Class Lie.a
Dam Contracmr
ARCHITEl DECLARATION
1 understand my plans shall he used As public retards
�a Licensed Ptulmeanal
5g 3 OWNER-BUILDER DECLARATION
4 i 1 hereby affirm that 1 am exempt form Use Contractor's License Law for the
O O following reason.(Seeman 713 1.5,Buslnus and Pro(esiwm Cade:Any city or aunty
g which requires a permit to comrucL altar.Improve,demolish.m repair any structure $15000
Zea
pd.,Act its Inc.,also main.thapplieanlfor such permit m fileasigned anconal
ggFFF< that he is licensed pursuant W the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
dg (connmcacalviiih Scnion7")of Division3 nftheeusnessand ProfusionsCode)ar
3 met he is exempt tl¢¢fram and Um bub for the alleged exampaan.Any violation of
Scedon 7031.5 by airy apptiant(Lir a permit subjects the applicant W a civil Penalty of
not more than five hundmd doll.(5500). er Occupancy Type
O 1,u owner order property,or my employees with wages As Weir sole compensation,
will do the.,Lead theaauctum is (intended moffrmd forsale(See.70th,Businev
Required Inspections
and Professions Code:The Cantsecmrs Liana Law docs not apply W An owner of e q ns p
propelywho builds orlmpsowat Narcan,and whodoessuchwarkhi uelfor Waugh his
own emplayas,provided that such Improvements are not intended ora@red formle.If.
however,the building or Improvement is sold within arc year of completion.the owner. A -
bullda will love the burden of proving that he did not build or Improve for purpow of
ata.).
O 1,u owns,of We property,Area exclusively...matesing with licensed comnebn to
constrect the project(Sec.7044,Business and Professions Cotler)The Conuecmr's Li.
am raw does not apply W an owner of property who builds or Improve themes.sod
who comsatts,for meta projects with a eon rmlods)licensed pursuant mole Conmumor's
Liam Law.
O l am exempt under Sea ,B&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury am of the following dedmulons:
I new and will maintain a Certificate of Consent to self-Insom for Wormes Compen.
satlon.AS provided(m by Section 3700 of the labor Cade,for We performance of the
wmk for which this Tamil is Wood.
O 1 haw a,ud will maintain Worices Compensation Insurance.As required by Section
37ODof the Labor Code.fm the perfmmsoaof the wart forwhich this permh is issued.
My Workers Compensation Insurance aura and Policy number AM:
Cartier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS
COMPENSATION INSURANCE
(Thlssecdon recd not ccomplemd if the permit is We=hundmnd dollem(SIM)
or las)
1 unify that in the parfomuanee of We work for which this permit is issued.l shall not
employ any person In my manorso as W became mbjret tu Use Workeri Compensation
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifinm of Exemption,you should
become subject W the Workers Compensation provisions of the Labor Code,you must
wJ O forthwith comply with men provisions or this permit shall be deemed ranked.
'Z� CONMUCfION LENDING AGENCY
(~ Ihrebyaf(lrm that there Is a construction lending agency forth part=.=of
aithe work for which this permit is issued(Sec.309'1,Civ.C.)
WM Q Lander's Nsmc
`0.z Lenders Address
V Q 1 eatery that 1 taw read this application and sum that the above Information is
I7+ torten,I agree to comply with all city sand county ordinances and state laws relating W
building construction,and hereby authad.minsentatims of this city W enter upon the
G alive-mentioned property fm Inspection purpesa.
(We).gra W pw,indemnify and kcep harmless the City of Cupertino against
.F.in liabilities.judgments,costs And expenses which may In any way stere agalnal said City
in
APPLICANT UNDEmianco of the RSTANDS ANDOf WILLWWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULAMONS.
Re-roofs
Signuurc afApplicaDDam
HAZARDOUS
US MATE RIALS DISCLOSURE Type Of Roof
WIII the applicant or future building eaupsoutarc or fondle licardousd Safety ety
As definW by dm Cupertino Municipal Code.Chapter 9.13.and dm Health and Safety
i
oat,section 2553:(1)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONoPill the applicant or future building occupant me equipment ear dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
t Aoya,dous tar contaminants As dafinad by the Bay Arca Air Qual ty Management all new materials for inspection.
istrict?
Oyer ON.
I haw mW the hazardous materials requirements under Chapmrd.95 of the Califon.
ria Health&SafetyCom.Sections 25505,25533 And 25534.1 undermnd that if the Wilding
docs not comedy haw a tananl that it is my mmenexhility W notify the occupsot of the
requlremcns which mon W mel prior W issuance of a Certificate of Occupancy. Signature of Applicant Date
ownor0,.aWary<dagent Dam All roof coverings to be Class"B"or better
v