04070060 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONT A1C nR;YN 'U "C C11�
BUILDING ADDRESS: PERMITNO.
04070060
OWNER'S NAME: PERMIT ISSUE DATE
JO
JE: SANITARY ND, 2 OL NO.MALTOR
ARCHITECTIENGINEER: BUILDING PERMMNFO
BLDGELECT PLUMB MECH
ttaj LICENSED CONTRACTOR'S DECLARATION - O O
1 hereby ) f that 1 em licensedB.undcr nd po provisions of.Ctu Chapter Y(commencing Job Description �I� w �D
with Sec'hereby
from thatI. oli NCBmineu end Pmfcaslor Coda e9(WroCenreis I(A�`
infuuro rcec p REMODEL POOL/ADD SPA
5 x Licence Llc.a
z� Dam GSOE CONTRACTOR: ALTRUISTIC POOL
A C SD N
Ky u my mcdss crecnds DEC ZOOI.
zidu T
5 G Li mfcssiontl
OWNER-BUILDER machoDERDECLARATION BUILDING
E 2 1 berehy.(Bete on I em exempt from Ne Canlns Cc license taw for the
O following meson.(Section]1131.3,Businus and Pro(msiona Codc:Any city or county ■G
N m which requires a permit to construct.alter,Improve,dcmnllxll,or repair any stnlLWm
•u prier In its issuance.also outmost the applicant for such Permit file a signed statement
that he is licensed pursuant to the pmvialoos of the Commuter's License law(Chapter 9 Sq.Ft. Floor Area Valu$ti�1000
yF$ (commencing with Salton 7000)of Division 3 of the Business and Professions Code)or
e 5l Nat be u eaempt therefrom and the hail for the illegal exemption.Any violation or
Section 7031.5byuryapplinnt for At permit subjecu the appli.t loaaivil penalty of APN Number - Occupancy e
not mom Nan five hundred dome(s50)). 32637027 . 00
P y Typ
❑1,a owrter of Ne property,ar my employcu with wage udteir wle eompena0on,
will do the work and thesNacluta b not intended oroRemd for side(Sm.7044,Businus Required Inspections
and Profesdam Code:Time Contractor's License Law does not apply m an ower of q p
property who build,or improves Moral.and who doca such work himselror through hit
own employee,provided that such improvements are not Intended oroffera t for Wn If.
however.the building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of proving that he did not build or improv for purpose of
dc.).
❑I.a owner of Na propeny,am exclusively contracting with licensed cauracton to
construct the project(Sec.7(44,Business and Profusions Code:)The Conmneter't Li.
corse law docs not m an owner of property who builds or Improves thereon.and
who contracts for such projects wish t commentor(s)licensed pursuant m Me Contractor'.
License taw.
❑I am exempt under See .Bk P C for this manors
Owner Dam
WORKERS COMPENSATION DECLARATION -
1 hereby"no under penalty of perjury one of the fallowing declarations:
hew and will melnlain a certifies.or Consent it a151mum for WalteM1 Cooper.
nation,u provided for by Section 3]00 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 haw and will maintain Workees Compensation Warrants,as required by Section
37W of Ne labor Code,for the performance of Ne work for which this permit is issued.
My Wormer�Compensation lnsunue carrier and Policy number oto: -
Ca ' �D Polity Nov Q
CERTIFICATE OF EXEM MON FR01 ORKERS'
COMPENSATION INSURANCE
Clhb amlon need not be cnmphoal Kilns permit is forone hundreddollam(51g) ,
or los.)
I certify that in the performance or the work for which this Permit is louse,)"I not
employ any person in any manner an as to become subject o the Workers Compemadon
Laws of Celif.mia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccuill ate of Etemptor.you should
become auhjcm an the Worker's Compensation provisions of Ne labor Code.you must -
.J Q
E! forthwith Comply with such provisions or this Permit be deemed revoked.
' CONSTRUCTION LENDING AGENCY
(—i 1 hereby alarm Nat More is a construction lending agency for the performance of
!YNe work for which that permit is issued(Sec.3097,Co.C.)
LL7 Q Limmefs Name
Z Iandeh Addaas
U 0 I sonify that 1 have red thi,application and site That she above ofmmNun is
IL P Comm I abra in Comply with all city and County ordinances and ism taws totaling in
0 V building construction.and hereby wNorise mincaentadws of Mia city to enter upon the
W ahovam..tinned property for inspersion purposes
Q, (We) S.to ave,indemnify and kap handes,Ne City of Caperton.against
y Ilabilide,judgments,toss and eaMmes which may in any way accrvc sgairol said City
YJ z in consequence of Ne bnmin of Nis permit.
.. APPLICANT U ER S AND WILL COMPLY WITH A L N NPOINT Issued by: Date
So
A
Re-roofs
S' un of Appl'a onuesmr De
AZARDOUS MATERIALS DISCLOS RE Type of Roof
WAIN pliant or futon building ocapalmon or handc aardum material
m defined by the Cupertino Municipal Code.Chapter 9.17,and the Health and Safety
Coda,Section 15532(11)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t haraNnu air rommirums as dcfiud by Ne Bay Arta Air Quality Mamgcmcm all new materials for inspection.
District?
❑Yes N.
I have mad Me hvaaduusmatedalsrequitomenu under Clupter6.95olthe Califor-
nia Health h Safety Code,Sudom25505,25533 am125534.1 undcrmaod Mallow huilding
does not current he t my responsibility to redly the atop or the
Md.h. le I prior issuaa en;fiem Signature of Applicant Date
r auth.ri.dagen Da All roof coverings to be Class"B"or better