04030164 CITY OF CUPERTINO d°' �^ ^+Jce sdb'e7kthtx� trr*� N
BUILDING DIVISION PERMIT iCONTRAC�TOR INFORM.A.TION` ��
BUILDINGADDRESS: LIFETIME POOLS INC PERMIT NO.04030164
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHTBLT/ENGINEER: BUILDING PERMIT INFO
BLDG ELEL7 PLUMB MECH
�0o LICENSED CONMACTOR'S DECLARATION C _ O O l�
0 1 Wmby afro that 1 am limned under provisions of Chapter 9(commencing Job Description
with Section 7IX10)af Division Sof Ne Business and Profcuioos Cade,ander license la
�^< in full fortt aB0 cffea /
LieenseTja� (.- llC 7 �' SWIMMING POOL
^e Da\¢, / Contractor /_/ - /M£ A
y O MI uMertund my plana elhall be used
an
urS llltcrtnrd
3 sad Licensed Professional
5 OWNER-BUILDER DECLARATION
f 1 hereby affirm that I am excmpl from the Coolncmr's Licenan Law for the
NO following mason.(Section 703 1.5,Business and Ptufusiou Code:Any city or county
k$2 which requires a permit to construct,alter,improve,demolish,or repair any structure
FZ�^ priors its heo ec.al..requires the applicant for curb permit to file.mgnedstsemcnt
p � Net heueieccuedpoomma1.the provisionofthe,Contractor's License Li.rClnpe,9 Sq.Ft. Floor Area Valution
y (conern ng with Section]000)O(DivuionJ.fthcBusinemandProfecinme.M)W
ton W u'.N thuofr.m and use beau for dre alleged exemption.My violation of
Section 7031.5 by any applicmt for a permit subjects de applicant o a civil penalty of
not mom Nen five hundred dollars($300). 3 MNJtJFkr0 0 Occupancy Type
❑I.as owner of the property,or my employaes with wage"their rule compensation,
will do the work,and No structure is not intended or offered for sale(Sm.7(1 Bruins
and Professions Code:The Convacmts Licene Law dao not apply to an owner of Required Inspections
property who b uIdsorimprovesHereon,endwho doessuch work himselforthrough his
own employee,provided that such Improvements art notlneMW monnrd for Wa.IL
however,Nebuilding orfmpmvementg shout within one year of competiw,throw of
builder will have IW Wrdm of proving this k did not Wild or improve for purpose of )<X2,
sale.). Is
❑1,as owner of the property am exclusively contracting with limmed contractors to
convect 701e pmjem(Sec.70Business and Profession Code:)The Contractors LI- �/
come Taw dots not apply to an owner of property who Wilds or improve Nemon,ad. tv/
who contracts for such projects with a contmemr(s)licensed pursuant m toe Conmclors 77
License Law. ,
❑Ism mmerat untiv See. ,B&PC for this..on
kI
Dae
WORKERS COMPENSATION DECLARATION
1 hereby affbm under penally of perjury ow of t e following doesistione
wandwill maintainu provided for by Section 3700 of dm Labor Code,for the peAOnnanm of ftor
wkfor which Nis permit is issued.
have and will maintain Worker's Compensation Insurance,u required by Section
7 of Ne laWrCade,for the pertarmance of the work for which this permit is issued.
My W iters Compen Wi len Ionization"cand Policy number art:
sritfb XLyl� aa:OL-t3G5bS�
CERTIFICATE OFEXEMPnOM WORKERS
COMPENSATIOtt}} SURANICE
(Thlasectim wed not W compleed if IW permit is forone hundmddollan(5100)
or lets.)
1 certify that in the performance of Ne work for which this permit is issued.I shall not
employ any poison in any mannerso as to become subject to the Workers'Compensnlon
Lam of California.Data
Applicant
NOME M APPLICANT:If,spot making this,Cenl O"m of Exemption,you should
become subject on the Worker's Compensation provisions of the LaWr Code,you must
0 O forthwith comply with such provisions or this permft shall W dmmed newmad.
,z.,r4 CONMUCDON LENDING AGENCY
[-+� Ihereby alarm that them is a commuclon lending agency forth,performance of
C the work rot which this permit Is issued(Sec.3097,Cl,C.)
0 Lendce,Name
=z IanMrc Adder..
V 0 I mnify Nat I Nw mad Nis applirnian and sum Nu IW eWve information u
D. F-' correct.1 grec to comply with all city and county ordinances and some laws nesting in
0 V Wilding construction.and hereby autharin mpreenmivn of Nis city to ester upon Ne
(4 ahavcmcmiancApropeny(an minimum.which s.
may
fy (We)agree to save,indemnify and keep humless the City or Cupertino against
Z iscrosequeri me the costs and expenses which may in any wryacrneagainst mid City D
t.)z in PLICA T of the pasting of this pcnnit.
APPLICANT UNDER ANDS AND WILL COMPLY WITH ALL NO POINT Issued by: Date
SOURCE REWLA h,
n not t ans/Canmacu r "^'pDid Re-roots
1. HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding acceptant store or handle havudam material
as MOnctl by the Cupertino Munici
Will Ne applicant or forum Wilding mcupam use equipment or devices which Cook,Chapter 9.12,and Ne H"IN and Safety
Code,Section 25532(¢)? All roofs shall be inspected prior[o any roofing material being installed.
Cy. Nu
If a roof is installed without first obtaining � g an inspection,I agree to remove
emit horandous air coneminants u uncut by the Bay Ana Air Quali y Management all new materials for inspection.
District?
oY" NO
I have mad her husrdous materials requirements underCheptcr 6.95 of tW Calror-
.I.H"Ith h Safely COM,Sections 25505,25533 and 25534.1 understand thdifthc Wilding
dao not currently haw a comm*it is my mpomihility to Only the moment of me
requinmcnLL which must N He,t.ivaance.ra Cemgme.ro mpana' Signature of Applicant Date
3 All roof coverings to be Class"B"or better .
0 ar oris g u pan