04060111 (2) J�
CITY OF CUPERTINO CONTRACTORINFORMATIfIN ��
BUILDING DIVISION PERMIT k+r._ O ' a yq;,
_...
BUI DING ADDRESS: SWAN POOLS PERMIT NO 04060111
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY 0. YiAOL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+�oo LICENSED CONTRACTOR'S DECLARATION lob Descri h
�a p I he�eby�y�Px�ff"an Nnl I am IiavN under pmviaions of Chapter Y(commencing /�raa�a
[� wiNScxmj )of DiWeion3af the Businw aplproGuions Code.aMmylicenm is ■ INA�YD
in full fon'eZnd AI(Act. ✓-
044 ummec las Lie,, NEW INGROUND GUNITE POOL
,e L ARCHITECI-S DEC ON SEP 8 0 2004
y I undcrstkmyrhy plans shall he used u pamemnMM M! E
3,
Licensed Proat
fcssiun
OWNER-exempt fr DECLARATION ^ ■f��I
+� I hereby offirrn that I em exempt from the Conuecmrs LicenO Lew for the {®l U
ip0 following (Seem.7031.5.Busimsumal Profcted.Code:Any city or county
n3 g! which squires a permit m s atslmAa elan.cartoon,dcmolim,or apair any structure
prior to its issuance.also require Ibe applicant for such permit m Ne a signed smemem
Z�� that he is licensed pursuant to the provisions of the Contialea's License Law(Chapter 9 Sq.Ft. Floor Area Valu tion
es C (commencing with Sectlan7")of Division 3 of the Business and Profcasions Code)at
that he is exempt therefrom and the basis for the alleged exemption.Any V1014dCn of
Section 7031.5 by any applicant for a perrala subjects Nc applicant to a civil penalty of 3 7111V MIlt4erO O Occupancy Type
not mom Nan five hundred dollars($500).
o ownek.And
pmpmy,or is employesmcIwagesssthevmle c0mpenOdnn,
will do Newark ands: awnua u rot z Licend or a ftaniw clo for Ole(Sec.n an,owner
ces
and Rofwh obis Code:The vesderem.License law dans not apply lf an owner of Required Inspections
propertywho buildsorimprove Neeson,and who doeaaucbwork hi offered
redthrough his
own employes,provided prove h improwmw t are not Intendedofcompletion.m oercd for Ole IL
however,Ne building or improvement ie hath within one year of Improfor Ne owner-
builder will have the burden of proving that he did not build or improve for purpose of
Olc.).
❑1.u comer of Ne property,am eclusively convening with licensed contractors to
conswn the ancien(Sec.7044.Business and Professions Code:)The Contracmr'a Li.
cmue Law mos,not apply to An owner o'property who Wilds or improves demon,and.
who contracts for such projects wish a conlrmtor(s)licensed pursuant N dm Contractors
Lima.Law.
❑1 am exempt under,Sec. .B IS P C far his resson
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,am of the fallowing declarations:
have and will common aCenifiam ofConsem to self-insure for Worker's Comfort.
on,as provided for by Section 3700 of the Isbm Cade,for de Panama.of she
W
for which this permit is issued.
have and will maintain Worker's Compensation Inmrana,As required by Section
"Da of the labor Code,for the perfom mance,of Ne work for which this permit is issued.
My Workers Compensation Insumna carrier and Policy number am:
Cartier: A - N Policy Na. 4;W__
RTIFl TE OF EXEMMON ROM WORKERS'
COMPENSATION INSURANCE
(transaction Aced not be camp lead i f a he Permit is form=hundred dollars($1011)
as less.)
I certify Nat in the performance of the work for which this permit is issued.I shall not
employ any ach an in any mannerso AS in become subject to the Workers''Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cerinese of Exemption,you should
become Subject N Ne Workch Compensation pmviaions of the labor CMA.you must
.,0 forthwith aompty with such provisions or an,permit shall An dmmed mokcd.
Z N CONSTRUCTION LENDING AGENCY
[-� l hereby affirm Nat Nem is a construction lending agency for performanm of
!Yi> he work for which this permit is inued(Sec.3097,Civ.C.)
Q Lenders Nation
Z)z Lender's Address
J C 1 canify that 1 have read Ws application and atsu Nal Ne.bow Afmmadon is
BL E' correct.I agree m comply with all city and county aNinsnas and SUM laws miming m
Q V building convection,and hereby authonea repreenutiws of Nu city no Amer upon he
{27 ahnvA-mentioned property for irupection puryaea
it. (We)agree to Ove,indemnify and keep hi rmleas the City of Cupenino against
rp liabilities,judgments.casts end expense which may in any way game against mid City /
V z in consequence of the granting of this permit. l
APPLICANT UNDERST NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Soul EGULATIO Q �,�
M �1 — /�//�� �o y� g� Re-roofs
Siepat� Appli UCanuec r / Date
lJ/% x ' US MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant am a or handle haourdous.aerial
As defined by the Coconino Municipal Code,Chapter 9.12.and the Hearth,and Safety
Code,Section 25532.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya Co.
Will the applicant or future building occupant see equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II haysrdnus air matmainams As defined by Us Bay Ara Air Quality Management all new materials for inspection.
miaT
❑Yes �bb
I hawacedtheh,a U.ma 5, 5533.4 Z3underCamperd.95ofthe Califoo-
Tia Hna t erhoo tl yCedc,S t At. 2&I L IS 5533 end 255ility*dcrs y i th WCUp Wilding "
Jars oat curtendy how a an rat.Net it ix my asponalhillty m madly the mcupent of the � �-df„:. '
roqula Sieh must mel rior a issuance or a Ccrtincea of sacupenry. ?;”
7 Signature of Applicant Date g
0wl - aathmiu gent Dae All roof coverings to be Class"B"or better