06060041 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C�NTRACT�ORIIYE,OTtMA'�ION
BUILDING ADDRESS: STERN ROGER A AND DANA L PERMIT NO06060041
10418 PALO VI D
OWNER'S NAME: PERMIT ISSUE DATE
STERN ROGER A AND DANA L 2006
IHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+op LICENSED CONTRACTOR'S DECLARATION
%to 1 hereby affirm Nat 1 am licensed umkr provisions of Chapter 9(commencing Job Description
$IW with Section 7")of Division 3 of NC Business son!Pmfusiuu Code. tlmy license is
+« mrmlmxeander ,. P. NEW GUNITE SWIMMING POOL AND SPA
= Licenu s - Lie.
Contractor p ��— JC POOLS PAID FOR SL 6/6/06
i F p Da¢
7W ARCHrtEC`rS DECLARATION
f¢< 1 untlenou nd my plans shall be used u public records
Jct
s a. Licensed Professional
1 OWNER-exempt fi DECLARATION
2O C I hcrehy.(Aero on 11. exempt from Nc Contractors Licenu Law for the
LIO hollowingscazon. ermil 17(DL5,Business and Improve,
deiodi Code:Any city lacounty
<$ which its requires n permit re ennwthe alcor.impmsu dcmul W,ri e a sig any suumurc
prior to ialssuanepalw residues the thovisios.f far suchpcte.in License gocdsulcmcm
-ss< (Wmmencingwit pursuant to Nc of Divisuofofts,ft Buinessnd Prorlaw(C mic)or Sq. Ft. Floor Area Valu [�(](](]
r F�
(commencing with Section70M)and the
basis
3 of Migcdns and on.Any
Ction of
y�� Nat k u exempt Nmefrom and the buts far the alleged exemption.Any violation of
Section 7031.5 by any appliesedfm a permit subjects the applicant m a Civil Penalty of �,�1{py}ss`7.tNumber Occupancy Type
not moil Nan five hundred dollars(5500). 3 J /V L 047 . 00
❑1.as owner of Ne proper,y,or my employs.with wag.as Noir sole eompovwdon.
will do the work,and Ne su icmm is not intended Or offered for sale(sec.7(044.Business
and Profesdou Code:The Contncmes License law amts not appy he an no,of Required Inspections
ownproperty who
yces.pdsorimpror.thermrewmao dmaattcn work craffeortNough his
ownemploye.,provided perp chimprovementss. not intendedtoncused for. .IL
however,the Wilding wimprorpmmtumid withinone Wild of mmoveforto awe of
builder will have Cite burden of proving that M did rand Wild or improve for Purpose of
salt.).El / )))
1, s owner of a Sec.7 ,.B exclusively midessa ng with:)shed rat m es U.cotutmn Ure esojd, (See 7044,Business and Professions ender)The Comracmfs rad //
wholawamsnotappy tots own.ofpromny woo odporimprovhe Cotton.and. /
who cnnuacts for such projects with a contncmKs)liaved pursuant to the Contractors
Licenu Law. ^�
❑lam exempt under Sec .B hPCfw Nis recon (f
Owner Data
• WORKER'S COMPENSATIONDECLARATION
1 hereby aRn a under .at,,of perjury ow of the following declarations:
❑Ilam and will mainainaCutifiam of Consenttoxlf-imumforWorkefsCompcn-
.,ion,as Provided far by Section 3700 of the LaWr Cade.for the perfermance of de
work for which this permit is issued
1 have and will maintain Workces Compctuation Insurance,.volumed by Section
37W of due Labor Code,(w Ne performance of the work for which Nis Permit Is Issued. '
My Worker's Compensation Insurance artier and Policy number art:
Carrier. Ane''. Policy No.:
—� ChFICA 0' F EXEA1PIONFROM WORKERS'
COMPENSATION INSURANCE
(ITU section need not o completed if the Permit is fwonc hundred dollars(SIM)
ter less.)
1 sonify Nat in the p:rformane,of the wart for which this Permit is issued,I aball not
employ any Peron in any manMru M in become subject to the Warkut Compcnsauan
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccdificam of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Coda you mind
., O foMwith comply with such previsions,w NU Permit shall o domed revoked.
z" CONSTRUCTION LENDING AGENCY
(--t.�. IhcmhyalB tNce is coutroctinn lending agcvtcy�(�r Nc perfurmdsm of
CG> de work ter whichtmit is (Sm.309').Civ.C.)7j6 01,
W ~n- Lomier's Name
Isndc
z es Address t
U Q 1 codify that I have s.d Nis application and sate Nat use move Information is
IL. � codon.I agree to comply with all city and county ordinances and sale laws tinting to
C U building eonswction,and hereby aushori re representatives of this city to enter upon the
1 shove-mentioned property for inspection ferments.
(We)agree to save,indemnify and amp hdmises the City of Cupertino against
fin liabilities,judgmcnes,casts and expends which may in any way amus against saidCity /
Of thin granting Of
U Z s permit.
APPLICANT UNDERSTANDS AVND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATION
�6� 7—/, --D (, Re-roofs CT
Signature of ApplanpCordxtor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant done or handle haaardous material
az defused by the Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
Cade, 35333.? SElY. tSn All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without firs[obtainingan inspection,I agree to remove
,
Will the applicant or fume Wilding occupant useuseequipment ter shims which Pe g
and, air cyouceirt. az flood by the Bay Area Air Quahi,y Management all new materials for inspection.
District?
O Yes Nu
1 have mad the haaa d.materials tequiscmcna under Chapter 6.95 fthe Califon
nix Health&Safety Code Seeuws,25505.25533 and 25534.1 undersand the iftk Wilding
dots rot cmxntly hast a anent-W,i,u my ncxpo.ihility to minty Jc mupan,of Cc
revniemem, prh in.,be pp�orto issuance,of a ccoiBeam orZmpancy. Signature of Applicant Date
�ci ,ort -7-6 Dow All roof coverings to be Class"B"or better
Owneranuthomed gent Daa' g