03100100 (2) 4CIY OF CUPGRTINO t�+v vw;gw A, r �?.ie '+-s�^-s,? rum ;~ r
BUILDING DIvISIGN PERMIT CONTRACTOR INFORMATION Z_
INGADDRESS: LIFETIME POOLS INC RERMITN003100100
R'S NAME: 910 SAN ANTONIO RDE' (408) 738-1576 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!Oa LICENSED CONTRACTOR'S DECLARATION - C7 O O O
ca F 1 hereby affirm iliac I am licensed under provisions of Chapter 9(commencing Job Description
!ib wins tion i Wnof Dlvidon3ofthe Businea, Profession.,Cndc,and my license is
ta mrml ro ave ermct./_ JO IN GROUND POOL/SPA
i Licca los �- it.a _
i D C sem
CIIITECTS❑ RATION
i y a I understand my plans shall he used as pu he trends
iyU
0 Licensed Pmfeuionel
OWNER-BUILDER DECLARATION
<I 1 hereby affirm that I am exempt from the Contractors License Law for the
:
00 following reason.(Section 7031.5.Business and Pmfeszions Code:Any city ear county
a`�
i m which¢quires a permit to construct,alter,improve,demolish.or repair any structure pnor it)its iamance.alsorequires the applicant fpfsuah permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor a Litcris,Law(Chapter 9 Sq. Ft. Floor Area Valuation
IFo (commencing with Stelmn 74)00)of Division 3 or the Business and Profusions CMO)or
3 Nat he is exempt OcmGom and Ne basis for the alleged exemption.Any violation of 32648025 . 00
Section 7031.5 by any applicant for a permit ubjects the applicant o a civil penalty of APN Number OType
not mom than r hundred della.(sSBo). Occupancy Y YP
1,as owner of the property,or my employees with wages as their sale compensation,
will do Ne work.and the structure is not intended or offered for sale(See.7044.Business 103 - FER
and Pmressions CWc:The Contractors License Law does ret apply to an owner or Required Inspections
ptopenywho bunds or improscs contend,and who does such work himselfor through his 104 - REBAR
own employees,provided thmsuch imprawments are notmmaded oroffered ruraile.If, 107 — POOL/BONDING
however,Ne building or improvement is sold within one year of completion,the comer-
builder will have the burden or proving that he did not wild or improve for pumom or 3 01 — ROUGH PLUMBING
sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to 304 - ROUGH ELECTRICAL
Construct the project(Sec.7044,Business and Professions Code:)'I7m Contractors Li- 502 - FINAL PLUMBING ENERGY
ecrtse Law does not apply to in Owner of property who Wilda or improves demon.and 503 - FINAL MECHANICAL ENERGY
who contracts for such projects with a convacor(s)licensed pursuant to the Contractor's
License Law. 506 - GAS TEST
I
am exempt under Sec. .B 6 P C for this maven
510 - FINAL PLANNING
WORKER'S COMPENSATION DECLARADTION ate 511 - FINAL POOL
I hereby affirm under penally of perjury arc of the fallowing declarations: 516 - FINAL BUILDING®®®
Ihave and will (a,byvection 7M of Consent to Code.far pre Worker's Compere T-8 NAL
EC)
urian. r provided far mi Section 3700 of the laver Code.for Ne pertormarta of Um a V �f®Q®�
work Tor which this Permit is issued. Q ,g
❑1 have and will maintain workers Compensation Insurance,as required by Seeing MAR 2 g? 2004
300 of the labor Code,for the performance or the work for whichthispaarmmit is issued.
Myworkcr's Compeut 1 I icy Policy
nur_�fJ%D
y 7r'lC�/E�lR2rTIPi,CC MPENSATIONurnter am
IO ANCEORKERS' ®INIG
Y( ds section need not he completed ifine permit is for one hundred dollars($100d ,M
less.)
1 certify Nat in the performance of Ne work for which this Permit is issued.I shall nut
employ any mason in any manner an as to become subject o the Worker)Compensmion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,aper making this Ccnificam of Exemption,yens should
become subject to the Worker'a Compensation provisions of the labor CWc,you mug
�O forthwith comply with such provisions or this perm it shall be deemed invoked.
ZN CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a conztructind lending agency fm the performance of
x INC work for which this permit is issued(Sec.30V7.Civ.CJ
21 QLenders Name
L Lender's Address
Z) z
;J Q 1 cenify that 1 have read this application and sate that the above information is
y f-' cmrec.I agree to comply with all city and county ordinances and sum laws slating to
V building convection,and hereby emhmiae«pmgmes ativof Nis city to cnsr upon the
(We)egse m save,indemnify and keep harmless the City of CupertinOa gainst
rg Iititainies,judgmen¢costs and expenses which may in anyway accrue againgsadd City
..) z irc,hWh,enee OfthOgmnringof this no
^ APPLICANT UNDERSTANDS ILL COMPLY WITH ALL NON-POI Issued by: Date
SOURCE REGULATIONS. /
sign Re-roofs ornrp env actor ❑
ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the ap eantmfoture building cecuponuume or handle hasmdous mistrial
as defined by the Common Municipal Code.Chapter 9.13,and the Health and Safety
caper s 25532(a)? Nu All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building If a roof is installed without first obtaining an inspection,I agree to remove
pct g occupant esu e.Air Qu eat knots which
it weurdnus air conmminants as dcnncl by the Bay Arca Air Quality Management all new materials for inspection.
sistrict?
p YC' XNu
1 have sad dae havaNgus materials mquismcn¢under Chapter 6.95 of the Califon
nil Hcahh ck safety CWc,SCNans 25!15,25533 and25534.1 undersmed dartif the willing
does not Currently a tedank dam it u my rctionsibility In why the oacupzm of the
mquirementsw stwmetpnurwiagueegf.cenlhcamofOceup r Signature of Applicant Date
/19
Ow rt dmhwdagen, Da All roof coverings to be Class "B" or better