05040129CITY OF CUPERTINO
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BUILDING DIVISION PERMIT-, -
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BUILDING ADDRESS:
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ADAMS POOL SOLUTIONS
PERMIT NO. 0 5 040129
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OWNER'S NAME:
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.
PERMIT ISSUE DATE
VICTOR PEREYRA
3675 OLD S I ANTA R TTA
07126/2005
NE:
SANITARY NO. CONTROL NO.
,(925)928-3100
ARCHITECTIENGINEER.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MCC"
LICENSED CONTRACTOR'S DECLARATION
Job
I hammy fr.. I am licansood under practices of Clap., 9 (annarrealiq
that
MME 1)
with Section 7") of Division Sof use Business and Pleftestake, Code. and my,!!ccous, is
I. fall to. red.B.I.
NEW SPA & REMODEL PO
License Class _ Uc8
Dole- Contractor
ARCHITECT'S DECLARATION
/W/2005
he
I tandermand my plans Asti used as public recoids
Licensed Professional
OWNER -BUILDER DECLARATION
BUILDING
I thereby afflon that I am Exempt from out Corclacclor'i Umnse, Law for the
followingmason. (section 7031.5. Business; and Professional Code: Any city or county
which requires a pernall to consontool. affle'. hopmem. done.fish. vert say strucau.
4�25000
prior it) its issuance, also tfires the applicant for such permit to flic aligned statement
W is licensed to he the Copmeater*s U.. Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuer, pon,iskinsof
(commencing with Section 7000) of Division 3 of the Business and propulsions Code) or
Nat he Is enternin Ocreltrum and the basis par the alleged ciaminflon. Any violation of
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J AFN 907iair
Occupancy Type
Section 7031.5 by any applicant for a permit subject, the applicant In. civil penalty of
not mom thEarn Irm hundmal d.1hous (M],
01,Uownerofftpmpcny,mmycmploy=wiffi"tEnwftkwlc-cmpcmdon,
will & On, work, and the structure is mat intended Or offounal forandat (Sm. 7044; Business.
Protection, Code: The Contractor's Liberia, Live does W
RequirealnspeIitions
and not apply an owner.of
property who builds orimprows demon. and who doessuch work himsefforthrough his!
=toy=. previdi that such improvements are nothounded orofteand porwdex,z
the building or Improvement I. mid within am yes, of completion; dmmvnm-;
mifs
builder will have the burden of Forcing that k did Out Wild w Improve fear Purpose of:
t.'O
ne
coretruct the Project (Sao' 7044. B Proftelsions; Cadk:) The Coruscate, Li-
conse Law does not apply ut an owner of property who builds at Improves themon. and
who cortuacts for such projects with conuractor(s) ilmessand puriumn to the Counselors
License Law.
❑ lam a., lander S B & CLfor M6an
-P Lhis
)6nor Dac
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WORCOPENSA ONDECLARA ON
A
lkmbyalis un&rpent,yo(Mduryaha offtfollmingd imtion:
I la.. and will maintain a C.mfi.mofC cmiummanif-)nstartforWoriale.Ccurpoll.
pe,'.a. . provided far by Sued.. 3700 of the Labor Cod., for the perfourromm of the
for which this permit Is isprood.
CI ban and will maintain Walker's Compensation lasmomm, as required by Section
37300 of the Later Code. for the, performance of the work for which this parack is bound,
0
My Wcorker's Compensation baeuorcx caner and Policy roulack, am:
My
a
Carrier Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section read not he completed little permit Is forone hundred dollars (SIW)
or East.)
I carfify Out in the p,uporamnese of the work for which this penct, is Issued, I "I not
employ any plemen In my morma, so '" to WaftraCepapensadon
Laws ofcslirand.a'-
Applicant
t
NOTICE TO APPLICANT: If. eMr making this Cenirl OrEltillpflon, you �ld
become subject to the Worker's Compensation provishal the Labor Code, you mot
forthwith comply with such provisions or this parmil shall W deemed revoked.:
I
CONS RUCTION LENDING AGENCY
arrot
for the rm an ce u('
performance
ft weak for which this block Is ist (Sm. 3097. Ci,. C-)
Leaders Name
Lender's Add=
I artily that I have =4 this application and am; Oil No shove Informed'. I,
comet. I qmc in comply with all city and county orcinsurces and same hors icltulpg; to
building construction. and Inumby alumnae repnomminor; of this city to cmc) upon No
above-mentioned property for impaction purposes.
I
(We) .9. in .., indemnify and keep hithanim, On, City of Cupertino against
Ilabilitim judSmanots. costs and expenses which may In my my ancrate gains, aid City
,
in catrouposence or the snarting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
'I,
Issued by: Date
SOURCE ON
r
Type of Roof
.'Z:Re-roofs
(!M!S(_�Z
Stimulate ol'AppittAvc..'ract., I I Onto, I _
HAZARDOUS MATERIA IJES DISCLOSURE
Will line applies., or to,. holding occupant sime or loundi. lumandous, material
as dfirmi by the Cupcolm, Municipal Cons, Chapter 9.12. and the Health and Safety
Same. 25532(a)?
0y.
All roofs shall be inspected prior to any roofing material being installed.
ufr
WHI future Wilding devices
.:If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or occupant use equipment at which
hamnlous air contaminates a dcgncd by the Bay Area Air QQAIhy Minalamenti�
'piall new materials for inspection.
let?
I
El Yes
I have mad the haucudousmaterialsmaquipunsents underChapwr6.95 EdOcCalifer.
i
nice SarmyColde, Sections, 25505.25533 W25534, I understood Out ifft building
does not Economy him . tenant, ME it is my responsibility W E101ify On OmUPEhI Of due
ta)o . Ch tom L W f C fil Lcofor y I
pazn Me PrEw" -7 Z"'IA
- Signature of Applicant Date
Mr
All roof coverings to be Class "B" or better
.
Owner ormthorrized a;cm ops f