08080196 CITY OF CUPERTINO
BUILDING DIVISION PERMIT rokMORMa
BUILDING ADDRESS:
PERMIT NO.
10495 SCENIC BLVD TBD — TO BE DE '
OWNER'S NAME: PERMIT ISSUE DATE
: A CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION
e I hereby am.Nat 1 am li¢vN under provisions ofclas'.9(ttournmeng Job Description
slut with Session 7000)of Divison 3 of NC Business and Professions Code.and my licensee
7'ey i.fell f°rccamefccw INSTALL FIBERGLASS POOL & SPA W. AUTO SAFETY
y z License Class Lia.0
=Fp Doe Contracts, COVER
ARCHITECTS DECLARATION
�wU I understand my plans shall he useda public records INCLUDES RETAINING WALL
v
g LLo to Licensed Profnssional
I OWNER-BUILDER DECLARATION
E1 hereby alTu n that 1 am caempt from Ne Cantractots License Law for the
no following mason.(Scetisn 7031.5,Business and Professions Cote:Any city sf only
K s v which mquirm a permit to construct,alcor,improve,demolish,or repair any structure
yai prior m its issuance.also rtquires the applicant for such permit to rile a signed statement
< thathedlicensedfuctiontotheprevisionsofthcConwcmhLittvelaw(Chapter9 Sq.Ft.Floor Area Valuation
y.a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt Noefrom and the basis for do alleged es<mpdon.Any violation of $60000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not tort than five hundred dollars($500).
35706015 . 0 0
❑1,as owner of the properly,m my employees with wages ss their role compensation,
will do the wart.and rhe s"cmm is not intended or offered fonale(Sec.7614,Business
and Professimis Cad=:The ConuacroR License law does nol apply to an owner of _ Required Inspections
Property who builds or im proves Usemon,and who does such work himsel f or through his
awn employees,provided that such improvements arc not intanded osRernd for We.IL
however,the building or impmwmenl Is sold within one year of completion,the comer-
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
I,as owner of the property,am esclusivelY contracting with licanad conuaawn to
construct de Project(sec.7D04,Business and Professions Cade:)The Constituent's Li-
ttnu law dour oat apply m an owner o(PmpenY w builds ar improves tberem,and,
who cormek for such progim iWasantracmr(s)1 dpursuantmthe Cantracloh
License law.
❑
I.eacmps
"RATION
40 I hereby amrm under penalty,of perjury one of she following declarations:
0 1 ham and will maimain•Cenifieam of cmacm m self-Insure forworim's Compen-
afion.as provided for by section 3700 of Ne labor Code.to,one performance of the
work for which this permit is iaued.
1 have and will maintain Warke',Comperwuon 1 wradi as,mquircd by Session
3700 M the labor Code,for the pvformanee of Ne work for which this peredit 4 issued. '
My Warker's Compensation Insurance canner and Policy number arc:
Cartier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Misseetion need Imlbccompli cd if the permit is forms hundred unit=(5100)
or th s)
I ramtify thvt in the pert arcc sf the xork for Qhich this Permit it issued 1 shall not
employ any person loan
of Exemption,you should
become subject he the We Campcslsktion provisions of the Labor Code,you muss
.J O foMwids comply with such provisions or this permit shall be deemed mvukcd.
Z7) CONSTRUCTION LENDING AGENCY
[-�.. I hemhyamrm that Nem isaconsmnmction lendingagency for me pe,formai of
!Yi Ne work for which Nis permit is;issued(Sec.303'1,Civ.C.)
W� A Lenders Name
M z Lenders Address
V Q 1 certify that 1 have mad this application and sant that use above ufommidim is
D, comm I agree to comply with all city and county ordinances and state laws misting to
.C) building construction,and hereby amhodre mpresenmive,of this city to enmr upon Nue
Lc shove-meoumud property for inspection purposes. —
F 6, (We)agree m ave,indemnify and keep harmles,the City of Cupertino against
In Iiabilides.judgmems,costs and expenses which may in any way acerae agaimtaid City
(„)z in consequence of the grant g of Ni Farm . L
^ APPLICANT UNDERS S NO WIL CO P WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION .
Re-roofs /
Signature of Appliran Can mr Date
HAZARDOUS"ALS DISCLOSURE Type of Roof
WII1 Nue applicant or future building et store or handle hmardous matmaterialas ridefined the Cupertino Municipal Cade..Chapter 9.12,and Ne HcaIN and Safety
Cods,scctionzsslz(a)+
❑Yu �No All roofs shall be inspected prior to any roofing material being installed.
40 Will the applicant or future building occupant use equipment or tevicea which If a roof is installed without first obtaining an inspection,I agree to remove
emit ho>a dons air contaminants u dtfined by the Bay Arca Air Quality Management all new materials for inspection.
District]
❑Yes No
Ihavemsldcha>ardous akmtryimmcnss dcrommr495ofthcCalifo-
niaHdNkSafctyC99ddcc.Sfcti 25535and255 a.ImvkramW Nat arc building
docs not,womdy h+se'a ant.deal it k mil tuy4nmlpjy�oavpanl of Ne
mGuimmcnts which nice` "pro, f. imasido, ami' Signature of Applicant Date
own,nr a°moot;>edas=nt � Dam All roof coverings to be Class'W'or better