01050129 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU I LDING ADD10525 MADCONE CT. SWAN POOLS PERMIT NO. 01050129
OWNER'SNA"ECURT & SHIEL.A BERG 1.495 S WINCHESTER I. �P'�,f'cnrloNs 001
tON1i (4 00)866-6893 SANITARY No. CONTROL NO.
❑c% ARC]111'12C'FIENGINI711k: ' BUILDING PERMIT INFO
00
u(i BLII'L CLI— 'I. NIB
_I MECI]
Z,4 SNO< LICENSED CONTRACTOR'S DECLARATION Job Descrl loo
1 hereby afuren that 1 stn Iicenwd uad,,Pmvlsl.I.of Chapmr 9(commencing
F -� wimsecr uag)rno'.visirp3annrRr.mrsm,arromssmp,c epwmy'i '"`0 INGROUND 51� SGLFT.. GRUNITE P OL & SPF
in li force and elll. e
K z< Lie •Claes, '•� Lie,g s H I l8
'u; G Il' e—5-1 �_f ndf:ul'nacr's ri'eci ntRnTdl2n.P�CS= '
1 unaemana.ny plans.la(n be used as pumie rea,rds s
$Wi
�' Licensed Pool ssim,al
OWNER BUILDER Broju IiR DECLARATION ��/O
,+�= I hereby aRnn that 1 am exmnPt room the Commaor's Licenw law for the
C xj which
,w y a IS do Ion S P less I I 1 C a y a county
Sp whorequires , o t hr. P d rh P ye. pre
prion [ Iso rty p pplba tf uchpc 'uic -6t.J.ammcm
mon licensed dr oa n 1 n . rat c t , .L 1 tch pmry S FL Floor Area Va aI1Yp'p•t �'1�
(ro in eem Scnionomadte ,normealeged stolon Any
Cndu) 9' �TJYGYI
or hal ion 7 exempt therefrom and the h psis for lo alleged exemption.Any virlmlon
of Section a Th LS by any arplicam for n permi...hjttu[he upplicam to a civil perm(,
orpm more ora„live hm,pdrcd dml;rl(s5aE). APNiN1PPe1r08. E10 Occupancy Type
❑1,as no net of the poopen% w
or my employees with age%as their sole conpcnsalon,
will do len work,and the strnCmre ix len mended of offered rat sale(Seo 70a14.
dp.ine,pad rrorasion,C,.Ie:'I he Commcmr,License law does len apply to an 103 — UFE�luired Inspections
owner of progeny Who(milds or improves thereon,and who docs such work himself
r hrough his own employee. provided that such improvement,are not intended or 104 — REBA R
d ielcd for sale.It,however,the building or improvcmmi,is sold within one yart of
completion.the owneohullder will have the burden of proving that he did n(,[build or 107 — POOL/BONDING
improve for purpose of sale.).
❑I,a.owncrothe po,way.ane exele,ively coui prang with l icepsed comma ors to 301 — ROUGH PLUMBING
consumer the project(See 704-1.Business and Prohssionx Cnec:)The contractor s 304 — ROUGH- ELECT R I CAL
Liam%,Law does ort apply m an owner of propcoy who Milds or improves thereon.
and woo compacts for such project.,with a eonnactml.)rcemed pursuant m the 502 — F I NAI_ PLUMBING ENERGY
Commmor,neer.law.
❑I:nn exempt under See .IT k P C far his remon 503 — FINAL MECHANICAL ENERGY
Owner Date 506 — GAS 'rES-r
WORKER'S COMPENSATION DECLARATION
510 — FINAL PLANNING
I hereby of ion order penalty fir va,my nucof me tollowing drvarminnv.
. ❑ 511 = FINAL POOL
I have and will maletale m a Cenircam of Consent self-insure for Worker's
Cr..I,..afm,. as p:nd.ded for by Section 3700 or he Lehr. CmI , for me 516 , FINAL BUILDING
perrormanre al the work far which this permit is iswN.
Cl I "'eand will rue drip W..em,Com"oplion Insunnac.as revolted by Senion
r)(N d dhc Lobo Code tar the se,forn come A the work for whirl,do,permit is
eI
M1fy urlopes C+ompcnxmion Insurance carrier and Policy number am:
C,micr:Skf't__ Policy No.: SIB __OyOq_
CERTIFICATION OF FXEMPGON FROM WORKERS'
COMPENSATION INSURANCE
('Univ section neon nm R cnn,plmed it the Perini(Is for nuc hundred dollars
($100)or last
1 ecoid,that in the red nmmc rI be wank for which his permit is issued,I
shall not employ any Pearn in any manner w as to became subject to the Worker%
Con,rcnsition Law,of California,o-m
Aprlilum
NOIICE TO APPLICANT:If,after nuking(bis Cenilicam of lixemplem,you should
become suhlea m the Workers Camper-tom f visians of the Labor GNc.lou mart
O Q ooI'onhwlm annply with such provisions nr calx Iwr,niI shall be dmored revoked
z _
(•` ry CONSTRUCr10N LENDING AGENCY
I hernhv.nnl rod hat them is a ennvmetirn lending agency for the performance
of the work het which his permi,k iswed(Svc.3097,Civ.C.)
6. ❑ Wndds Name
D z Lender's Address
V Q I mnify,hm I have read hi.application and swat that he above Information is
lm F., caret.I agree m comply wish all city and county ordinances and state laws relating
Ot) u,hnilding anrnrolwo.md lrttchy arNnd,e,epreentme,ivof his any ,,cmerngm
he slave-mmnioned property lin impee(ion purposes .
}Fn y (We)agree m save.indemnify and keep har,nle,the City of Co,er ins against
V] liabilities Pulgment..coat,and expenm,which may in uny way accrue agairtt said
U z City inan,ri,marcol he grudau,ol,lo,wr nil. {/
APPI' ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Date
SO' lfjrl RTC_iln_A'NY.` ,L ..
mate of Applicsnucenwcmr aP Dam Voksh
nAZ RDOUS MATER1A1 S DISCLOSURE
WIII menpplicea(or dumre mdlhnsotc,pn stomo,handlehanardou,m:acrialah defined by the Corcoran Municipal Code,Chapter 9.12,and[hc Hcallh and Safety
Cad,Smtinn 25532fa)?
eve, ❑No be inspected prior to any roofing material being installed.
Will the applicamor future brildmg occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
coot hazardous air comaminams.as defined by the day Area Air Quality Management
Di,hce all new materials for inspection. Applicant understands and will comply with
❑ves 0 N all non-point source regulations.
1 Irene rend the Ir riablou, norchal,rnp:irenecros under Chapter 6.95 of the
`difomia Health R' FetvCode.Sections 25505.29533 and 25534.1 undersand that
if he Mildingdoe,no[currently have a tenant.that it is my resrym,ibiliy remedy the
cnpam rf the req:dremrnh which runs[M met prim to Issuance of a Ceniaeme of
eL'rp""cy' Signature of Applicant
Owner ,,:onrdred pgem Date All
C�VrrO� e �L S'I�(�I_ All roof coverings to be Class "B"or better
m
OFFICE