02100085 CI•I•Y OF CUFER•I•INO
BUILDING DIVISION PERMIT CONTRACTORANFORMATIONc
Bull-118elIDESSTOKES AV SWAN POOLS PERMITN®210,0v085
(20B CHUI 1495 S WINCHESTER BLV APPLICATITVY`1DV'/y2002
)NE: (408) 866-6893 SANITARY NO. CONTROL NO.
ARCHITECTIENGINHER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
as .that ILICENSED CONTRACnder p DECLARATION �Q
F 1 herehy afrrm that 1 am ucensad under provisions of Chapter v(commencing INGROUND SW I MdTMes9('T8 n & SPA
with Section) lfgof Division J o(Ne Busf�s and Professions one and my license is
08
ZO=N in full fort CHSct�¢ /— L
�Z License Cl.s /y.�yw� Lim.I G ®.`'
g j FF DaisARCHITECTS D."toA N
z< 1 understand my plans shall W uwd ..,lira r ds
KLL;� LmcnscdPmfessiumd JUN 1 2 2003
S OWNER-BUILDER DECLARATION
�t�i<Z I hereby Militia that 1 am exempt from Inc Cumracmr's License law for the $22000
w—p0 following reason,(Section 9131.5.Business and Prnfcsxinns Cede:Any city ser rnunty
which requires a pmrnd to construct,alter,improve,demolish,or repair any structure BUILIDING
rZr .dor to its iammec, ho requires the applicant lou such permit to life aligned statement
qq 6 tial he is licensed pnssuunun the provisimmorthe CommamCS License law f6a,der 9 3S2l6f4 ff @)2AIl Valuation
a�Q (commencing with Section 700(d of Division 3 of the Business and Professlnlm Code)or
y — that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 703 L5 by any applicant for apetmit subjects Ne applicant to a civil Penalty of PNs-N Occupancy Type
not mom man nw hundred dnuars(s50Y. 104 — REBAR
0 1,as owner of the property,or my employees with wages as their sole compensation,
will do mn
e work,and the suuure is not intended or offered for sale(Sec.70,14,Business EffWt eef10B5
and Proessinns Cordo:'ITB ommuanr's License Law does not apply ,,an owner of 3 01 — ROUGH L uf
property who builds or improves thereon,and who deals such work himself or through his
own employees,provided that such improvements me not intended or-offered tar sale.If, 304 — ROUGH ELECTRICAL
however,me building or improvement is said within one year of completion,Ne owner
builder will nave the burden of Proving that he did not build or improve for purpose of 502 - FINAL PLUMBING ENERGY
sake.)_ 503 - FINAL MECHANICAL ENERGY
0 1,as Owner of the pfoprarty,am exclusively contracting with licensed contractors to 506 - GAS TEST
consumer the project(sec.7044,Business and Prnfeasions Coal The Contractor's Li.
cense law does not apply to an owner of property who builds or improves foramen,and 510 - FINAL PLANNING
who contacts for such projects with a contracmgs)licensed pursuant to the Comradur's' 511 — FINAL POOL
License Law.
❑
I am exempt under Sec. ,B&PC for this motion 516 - FINAL BUILDING
el Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury me of the following decla tions:
I have and will maintain s Cenumele of Consent in self insure for Worker's Compon-
safinn,as provided for by Section 3700of the lahnr Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Section
JIIp of the labor Cede,for the performance of the work for which this.moil is issued.
My Workers Compensation ser and policy number a�/����
Came 'P?TIEN/JO FROM
CERTIFICATEOMPE SATI INSURANCE WORKERS'
COMPENSATION INSURANCE
(This aecdon need nod hecompleted Ifthe permit is!more hundred dollars f ilgq
ar It,..)
I certify mat in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an as in become subject to the Workers Compensation
Lows of Celifomh.Doc
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the Labor Code,you must
OO forthwith comply with such provisions or this permi(shall he deemed manked.
z^ CONSTRUCTION LENDING AGENCY
[—i I hereby affirm thin there is a construction lending agency for the performance of
Eve the work for which this permit is issued(Sec.3097.Civ.C.)
0.W 0 Lender's room
z Lender's Address
U Q 1 wnify that 1 have read this application and sae that the above information is
(~ correct.I agree to comply with all city and county ordinances and state laws relating to
O U building consWetion,and hereby momiine representatives of this city to enter upon the
W above-mentioned property for inspection purpoes.
0. (We)agree to rove,indemnify and keep harmless the City of Cupenino against
in liabilities,judgments,costs and expenses which may in any way amore against said City
V Z On consequence of the Standing of this permit.
t••' APPLICANT UNDERSTANDS MD WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREG ATIO F�
Z—Rc-roofS
f ApplictumC actor Dale
11 RDOUSMATERIAISDISCLOSURE Type of Roof
Will enc appli ser furore building Oalcupam score or handle haaNnus material
s defined by the Cupenine Municipal Gam,Chapter 9.12,and the Health and Safety
le,Sc0C Yf52531?(a)? av All roofs shall he inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hasardous air cnnmminants as delmed by the Ray Arca Air Quality Managemcm all new materials for inspection.
rsulet,
OYcs FfNe
1 have mail the hasardnus materials requirements under Chapmrls9.5 of the Califor-
nia Hca1m&Safety Cede,Sccdom25505,25533 and 25534.1 understand mm if the building
deco not currently haw a len ,Nal it is my resrymsibility m notify the Oax�upant of the
rcyuircmcn room et rmissaanaef.Cra e.igfo..pancy. SignatureofApplicant Date
D•
/0.
amNaiscJ gem Dam All roof coverings to be Class "B" or better
U.Wnr