05050112 (2)CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION ,,
BUILDING ADDRESS:
LIFETIME POOLS INC
PERMIT &005050112
OWNER'S NAME:
PERMIT ISSUE DATE
E:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
HIMELECT PLUMB MECH
0 o E o
LICENSED CONTRACTOR'S DECLARATION
Job Description
I thereby affirm that I am licensed uio
m)cr pmvuns of Chapter 9 (commencing
P
with Section 70W) of Division 3 of the Business and Professions Codc, and my license is
mpull and e{kt. L
REVISION --STRUCTURAL REVISION
Lice - Lic. N
nsecC ass
c Con tr ter_
Dam -
NO NEW PERMIT ISSUED/ORIG. 405010031
ARCHITECTS DECLARA ION
I understand my plans shall b0 used as public recor&
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from on Communes License Law for tW
following reason. Section 7031.5. Business and Professions Code: Any city Or county
which requires a permit to construct, arcs, improve. demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit on rile a signed statement
he is licensed the Contractor License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant o the provisions of
$0
(commencing with Section 7000) of Division 3 of the Business and Professions CMB) or
Out he is exempt shemfrom and the basis far Ne alleged crampoon. Any violation of
APN Number
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than Eve hundred dollars (5500),
32644032,00
01. az owner f the popery, An my employees with wages u their sole compensation,
Required Inspections
will do the work, and the suuctum is not inMndcd or offend for ale (Sec. 7044, Business
and Professions Code: The Conuacmes License law does not apply to an owner of
propeny who buil& or improve thereon, and whether such work himself orthough his
own employees, pmvi&d that such improsemcna4 arc Act intended oroRerM ensure. If.
however, the building or improvement is sold within one year of completion, Ne owner
builder will have Ne burden of proving that he did not Wild or improve far purpose of
�s
sale).
❑ I, as owner of Oe Dropeny. am exclusively con oacting wish licensed mmmcom to
<D
construct the limper (Sec. 7044, Business and Professions Code:) The Contracts's Li
thereon, antl .
cents taw docs not applyje an owner or popery who Wilds or ant
to Ns
for such prolecu with a contractor(s) licensed pursuant to the Convector's
whonse
La
License Law.
❑ 1 am exempt under Sec. , B k P C for this season
Owner Dal
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
Worker's Compe
and will nationalA aCeri0eaM of Consentto self -insure for Workre
,onsAs provided for by Section 377 of the labor Code. for the performance of the
work for which On permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37W of the labor Code, for the performance of the work for which this Permit is issued.
My WorkkarrsCCorn enation Insurance carrier and Policy num ber AAM
nom
Carrier. 3 f -Thi QV a�5t7 Policy No.: I Sig Yn-1-o0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('this xenon need not W completed if the permit is for am hundred dollars (SI00)
Or Iexr)
I certify Nat in she performance of Oc work for which this permit is issued. I shall not
employ any person in any manner an as an become subject to the Workers Compensation
Laws of California. Date
ApPlicam
NOTICE TO APPLICANT: If, after making this Cenifcate of Exemption, you should
become subjccl to Ne Workers Compensation provisions of the laMr CMC, you mull
foMwhh comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 Mreby affirm that then its eosuu action lending agency ror the performance of
she work for which this permit is issued Sec. 3097, Co. C.)
Lcndcr'r Name
'
Lender's Add.
I Mer ify that 1 have read Nis application and seam Net the aWvc information Is
Correa I agree an comply with all city and county ordinances and sole laws relating to
building construction, and hereby authhrin, representallvea of this city to enter upon the
above-mentioned prorcrly, for Inspection purposes.
(We) agree to save, inthmnify and keep harmless Ne City of Cupenoo against
Iiabi ldu, judgments, costa and expenses which may in any way ..me Against said City
in consequence Of she granting of this Permit.
PPI nc
N3PNDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dat
UNDER�
SCj RE
Re -roofs
Type of Roof
^—' Mee b_3 4=j
Signature ofplicanr/Convstor Doe
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant or future building Occupant more or handle havardous material
as defined by the Cupenino Municipal Cade. Charter 9.12. and the Health and Safety
Me. Secti
on 256532(x)?
All roofs shall be inspected to any roofing material being installed.
❑ Yes ONO
prior
If a roof is installed without first obtaining ars inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
haordnus air conmminanu as defncd by the Bay Arca Air Quality Management
all new materials for inspection.
,via?
❑Yes r DNA
I have read the huxasdnus materials oqu modems under Chapter 6.95 of she Califoo-
nu Health A Safuy Cade. Sections 255)5.25533 and 25534.1 understood thatirlW Wilding
docs not fly K.A a Miami. Nat it u o my respmtsibility notify NC occupant of the
oyuir_c ennn chm tWmupdor m issuance ora amficlm ofoccupancy
Signature of Applicant Date
b
All roof coverings to be Class "B" or better
owner
or a horixed agent Data