01100062 (4) CITY OF CUPERTINO ��s,�
BUILDING DIVISION PERMIT a �k\ lit> � � Ass '`k ��N nim ICATF
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BUILDING ADDRESS:
OWNER'S NAME: PERMIT ISSUE DATE
2 Ol
kE' QTATV�MM
NE: SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapin 9(commencing Job Description
with Section 7")of DivI ma 3 of be Business and Professions Coda,and my license is
in m0foreeandeffect. SWIMMING POOL.
j la Z License Class Lk.M
n DareChooses.,
q ARCHITECTS DECLARATION
a I understand my pima¢hell he used as public records
a
O Licensed Professional
OWNER-BUILDER DECLARATION
<� I hereby afri m that 1 am exempt from the Commnor's License Law for the .
E p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y$ which requires a permit to consumer,elect.improve.demolish.or repair any structure $20000
Film prior In its istuancgalm minims she applicmt far such permit m file a signed statement
< 'hat he is licensed pursuant to the provisions of the Comment's Licento Law(Chapter 9 Ft. Valuation
a (commencing with Section 7000)of Division 3 of she Business and Professions Code)or
..
that he is exempt therefrom and Use basis for the alleged exemption.Any violation of,
Section 7031.5 by dry applicant for a permit subjects Ne applicant to a civil penally of 'F° QC panty Type
not more Nan five hundred dollars($500).
0 I,as owner of the property,or my employees with wages m their sole compensation. P\'1
will do Ne work andNmmuclum is natimended aroffered farmu(Stc.7W.Businnsa
and Professions Cade:The Comacurk License Law does at apply M an owner of Req(�ired nskp'ectionV'
property who builds orimproves theareon,andwho does such work himself or through his "
own employees,provided thalsuch improvements art notimended oroRered for We.If.
however,Ne building or improvement Is sold within one year of completion,Ne owner-
Wilder
wnerbuilder will have dre burden of proving that M did oat Wild or improve for purpose of .
Salo.),
0 1,as mvner of Ne property,am exclusively committing with licensed comma lata he
eonstmet Me project(Sec.7814.Business and Professions Code:)The Conommr's Lh
cense law does not apply to an owner of property who Wilds or improves Merron,and
who contracts for such projects with acom®cur(s)licensed pursuant in Me Contractor's
License Law,
0 lamexempsunder Sec ,B&PCfor Misreason
Owner Dau
WORKER'S COMPENSATION DECLARATION r-s
I hemby affirm under penalty of perjury one of We following declarations: / `� L ,
I have and will for by
a tion 37 0of as sent toLabor sclNCode,for for Worker's ce of on-Me / 5 _ D Q
moron, r provided for mi Session 3]00 of Me lobo,Code,for Ne performance of Dec
work for which this permit is issued:
0 I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code.far Ne performance of the work forwhich this permit is issued.
My Workers Compensation humane artier and Policy number ase:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPrION FROM WORKERS'
COMPENSATION INSURANCE
(Thissactien need Out W completed KIM,permit isforonc hundred dollars($)M)
or less.)
I cerifv Met in the performance of the work for which this Permit is issued,I shall not
employ any person in my mannerm in to become subject in the Workeri Compensation
Laws of California Data
Applicant
NOTICE TO APPLICANT:IL of or making this CaniOcala of Exemption,you should
become subject in the Worker's Compensation previsions of Me Labor Code,you mum
,J O for0with comply with such provisions or this mori,shall W demand revoked.
Z ti CONSTRUCTION LENDING AGENCY
[—i I hereby affirm Wt them is a construction lending agency for the perfannince of
E
Me work Cc,which Nu permit is issued(Sec.3097,Civ.C.)
W� Q Leaders Name
]z Lenders Address
C)Q 1 comfy that I have read this application and sum that to above information is
Ik.F correct.l agree W comply with all city and county on inmces and solo laws relating u
QU building construction,and hereby authorise represeroadva of this city to color upon ft
above-mentioned property far inspection purposed
Ws (We)agree to save,indemnify and keep harmlem the City of Cupertino against
Tq liabilities,judgments,costs and expenses which may in any way accrue against mid City
C)Z in consequence of Ne granting of this permit.
�^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
SOURCE REGULATIONS.
Re-roofs
Slgamurc of ApplicanVCaADData
HAZARRDOUOUS MATERIALS DISCLOSURE Type of Roof .
Will Ne applicant or forum building occupant erre or handle hatuatiousHealth
and
C defined io Ne 32( ?Cupertino Municipal Code.Chapecr 9.13.and the HuilN and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Na
Will the applicant or future building occupant use equipmem ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
It imum nus air comaminanes as defined by Ne Bay Area Air Quality Management all new materials for inspection.
Whitt?
❑Yes ON.
1 have had the hamolousamerials requirements under Chaprer6.95 ofthe Caiifor.
Hcollh&Safety Codc,Scefions3a505,35533 and 35534.1 mrdcrsund MatifNe Wilding
does not cmmndy have a sensor that it is my responsibility to notify the Occupant of Me
requirements which must W met prior m issuance of a Certificate of Occupancy. Signature Of Applicant Date
ria e
Owner or aathorivea agent Data All roof coverings to be Class"B"or better