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CITY OF CUPERTINO
= CONTRACTOR=INFORMATION :.
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
1; C) 1 CASTIDIR PIT
LIFETIME POOLS INC
FERMIT NO.
05010031
OWNER'S NAME:
PE OMIT IEBUE DATE
NE:
SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm bay 1 am lieeased under provisions M Chapter 9 (commencing
with Section 10(10) of Division 3 of the Business and Profassium Code, and my license is
in full forte and e(fec
Lie. a270a,92-INGROUND
POOL/SPA
Linen Csaa
Date Comramor
ARCHITECI'SDE ION
1 undersand my plasu shall w used u Public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm Not 1 am exempt from No Contractors License Law for the
fallowing mason. (Section II31.5. Business and Pmfessioos Cade: Any city or county
which rain., a Permit by construct, alar, improve, demolish, or at any urucmm
prior tar its issuance, also requires tic applicant for such permit to file a signed euoment
Ft. Floor Area
Valu tion
that he is licensed pursuant to the provisions of the Contractor's Uccuc Law (Chapter 9
Sq.
(Commencing with Section 7") of Division 3 of the, Business and prepositions Code) or
Nat be is exempt therefrom and the buss for the alleged exemption. Any violation of
6 F3`i"k 'V'915'
3 2NP4i. tnJIkIgr0 0
Occupancy Type
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mare Nan Bw hundred dollars (5500).
❑ I,uownerofsliepmprny,wmyemployccswithwaguuUxirsolecompenuuon,
('4 P Required Inspections
will do Ne work, and tie sweure is not intended or offered foram (Sec. 7I166, Business
and Profusions Codc: The Contracmrs Lt.. Law dos oat apply It an owner of
property who buildsor improver Meman, and who doassuch work himselfor through his
Own employers. provided that such improaemeno am not intended oroRered forsa m. If.
,�� _S
however.the building orimprovemanitiold within one year ofcumplefion. the Owner
build improve far
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t
builder will ban de widen of proving Nat he did not or purpose of
.in I.
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0 1, a owner of the propcny. am exclusively crnuaning wit licensed conmcmra to
the (Sec. 1064. Business and po !axion Code:) The Conaacmr's Li
A10
construct project
improver Nemo¢,
)
cense law does not apply to an owner of propcny who Wilds or and
e Canamra
for such projects with a nuactor(s) licensed pursuant thnt
who Contracts; Com
License law.
`/
r% f
l Sec. B k P C for this mason
❑ am exempt under
Owner Dam
❑ \i ti;'J
WORKER'S COMPENSATION DECLARATION
1 hereby affum under penalty of perjury one of the fallowing declarations:
1 be ve and will maintain a CewEcate of Consent to self -insure for Warkeri Compen-
sation. as provided for by Section Poo of Me labor Code. for the perf i mans of the
work for which this permit is issued.
❑ I bars and will maintain Workers Compensation luurance, as required by Section
3100 of the labor Code, for the performance of the work for which this permit is issued.
My Worker',Compensation Impnn¢ Carrie and Policy number am:
Carrier:Policy No.:M-1 �i6.
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Tits section need not becomplemd if ba family is (wane hundred dollars ($1013)
or less.)
I certify that in the performance of the work for which this permit Is issued. I shall not
employ any person in my mannerso u o become subject Mthe Worluei Compcuauan
'
Laws ofcmifomia. Data
Applicant
NOTICE TO APPLICANT: If, after making this Cenificate of Exemption, you should
became subject in tc Worker's Compensation provisions of the L &W Code, you must
faMwith comply with such provisions or this permit shall be deemed mated.
i CONSTRUCTION LENDING AGENCY
1 hereby a1Brm that Nem is lending7.Cagency for Nc perlurmana of
sal (Se.construction0
' the wort for which to permit ts kssucd (Sec. 309'!, Civ. C.)
LeadersName
Lcndacr's Address
U
j 1 certify that 1 have read this application and sate that 0e Met. infmmadon is
' correct 1 agree to comply with all city and county ordinanecs and sum laws relating or
building con oyetior. and hereby auchorim rapresenatisss of this city to enter upon the
above-mentioned properly for inspection purposes. .
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way acemc against saidCity
in consequence of the gra mg of this Permit.
' APPLICANT UNDE NDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCEREGU S.
Re -roofs
Type of Roof
.�— I
Si cc ppicanVCo oselor ' Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant more orhandle hanudous material
u defined by the Cupertino Municipal Code. Llaper 9.13. and the Health and Safety
Code, Section 25532(ap
All roofs shall be inspected nor to an roofing material being installed.
P P Y g
❑Yea ❑NO
g
If a roof is installed without first obtaining an inspection, I agree to remove
wll thc Applicant or faire wilding ocapant use equipmentor&,is. which
t
t haI rdous air contaminants u defined by to Bay Area Air Quality Management
all new materials for inspection.
alml
❑Yea ONO
I have read the hzaardsmsmaterialsmquir nenaunderChapter6.95oftheCalifor-
niaHwlthh Safety Code, Sections55$05,35533 and 25536.1 undersand they if the wilding
dos not camouy have a comaylp,11 it is my rupouibility to noufy Me occupant of the
mquimmeou welch muse dorm issuance of a Cenmat, of Occupancy.
Signature of Applicant Date
23_G)
All roof coverings to be Class "B" or better
Owner ori're agent Dae