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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION ,`
BUII.DINGADDRESS:
PERMIT N004010018
WNER'S NAME: -
PERMITISSUEDATE
.ONE:
-
SANITARY NO. CONTROL N0.
ARCHITECIyENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONnsedendR'SDECLARATION
JobDescription
1 hereby affirm that I am licensed under provisions of Corp.,C9 (commencing.
wish Section )IX ivision 3 of the BLiuceca ineas entl Pmfcssinns Cnde, end my license is
in full aand effect.
fra,'
DEMO (E) POOL FINALE®
Lt.... Class
Date Cuntmemr
ARCHITECTS DECLARATION
LTSDECLAc cards
I unticraunJ my shall he used Bs A ION
FEB 1 0 2004
plans public
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 exempt from the Contractor's License Law for the
BUILDING
following mnsnn. (ration ] 1. Bu and Co
mill Code: Any city nr county
which .quina construct, improve. dic any atruc.re
aper, import e, demolish,
alter.
permit re c�res
ea sig
prior to its issuance, also requires the applicant for such permit m Ole s signed statement
n the file
that
Sq. F[. Floor Area Valuation
menccenudpSecmnt.theofDivisiooftheCom.cmrsLicenulaw(Chop.r9
(commencing with Section]11110)MDivision3 the Business and
vi Code) or
.n. An
,herhe is tbcrtfrom add de Any violation of
baso for Ibe alleged eumpnt
Section 31.3 b any or to
Ne applicant to acivil Penalty of
wi�.ys,'
- 35WN21btllDear00
OCcn ane T e
ba.Sby
reddantforapermit¢ubjecu
not more Nan fro hundred dollars ($5110).
P Y YP
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do Ne work, and She structure is at intended woffered for sale (Sec. 9044, Business
and Professions Code: The CoOVaelori Licenu Law does not apply to an owner of
Required Inspections
progeny who builds orimpromes thereon, and who doessuch work himself orthmugh his
own employees, provided that such improvements are not Intended or offered formic. If.
however, Ne building or improvement is sold within one year of completion, the owner.
'
builder will have the burden of proving that he did not build or improve fur purpose of
mmd.
1, as owner of the progeny, am exclusively convecting with licensed contractors to
consumer the project (Sec. 7044, Business and Professions Code:) The Convactass LI-
,
cents Law does not apply to an owner of property who builds or improves themon, and.
who contracts for such pmjects with a contr¢mr(s) licensed Imminent In the Convectors
„
Lkcnu Law.
❑ I an exempt under Sec. ,B&P C for this .man
vena, - kuiE�Dale / 'a —�
W LAAATION
-
hereby affimt under penalty of perjury one of be fallowing cl ``iltl tions:
1 haw and will maintain a Cer ifica a of Comem to self insum for Workcr'sCompen-
tion, as provided for by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation InsurOnw, as required by b'CClldn
37W of the labor Coda, for the Performance of the work for which this permit is issued.
_
My Workce.Compensation loan... carie, and Policy numbers.:
-
Crorim: Polley No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
(This section need not Wcomplered if the Permit is foronc hundred dolln. (14,10)
or It
1 certify that in the valormmon of the work for which this permit Is issued, 1 shall not
employ any person in any manner an as u become subject o the WorkersCompenmtlon
Lawa of California. Data
Applicant -
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
b.....object m the Workers Cmeperwlion provisions of the Labor Code, you must
forthwith comply with such provisions or Nis Fermitahall be deemed revoked.
CONSTRUCT] ON LENDING AGENCY
I hereby affirm that Here is a construction lending agency for be Performance of
Ne work for which Ni¢ permit is issued (Sec. 309], Cin Q
Lender's Name
Lenders Address
I certify that 1 have mad this application and ants that the above information is
torten. 1 agree to comply with A] city and county ondi names and sure laws relating to
building construction, and hereby amhorre representatives of this city to en er upon the
liabvcros,judgm progeny for Inspection purprwhich
(We) agree In saw, indemnify and keep harmless the City of Cupertino against
liabiline......c. Cabe Ca.4 and ex a
Pamir. may in any WOyeCCNC against mid f.'Ity
of the this
this permit.
A
APPLICANT RSTAgirrinfingof
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by; Date
SOURCER W.ATJONS.
Re -roofs
-
Type of Roof
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S ,afApplicaMContm r
��e Ali
HAZARDO ERIALS DISCLOSURE
Will the aPPlicsnt tar future building Occupant store or here le brio rdous matcnal
_
az defined by the Cupertino Municipal. Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(.)+ /
❑Ya. (�Na
All roofs shall be inspected prior to an roofing material bei. Installed.
P P Y g, g
If a roof is installed without first obtaining an inspection; I agree to
Wits the applicant ar f/9lum building occupant sae equipment or devios which
remove
I harurdaus air contaminants m defined by the Bay Area Air Quality Management
all new materials for inspection.
vict7
❑Yes 4No -
- -
I have read the M ardnus mamrials mquimmenm under Chapbrb.95 of the Califor-
..
ria Health& Safety DaM, Sections 255115,25533 and 25534.1 undersand Motif ac building
_
docs not currently have a tenans at itis my responsibility to notify the occupant of the
requirements which must at pd.,1.is O Certificate of a.p.
Signature of Applicant Date
All roof coverings to be Class "B" or better
ow,. awhorizcJ *W Dom