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CITY OF CUPERTINO�Iy��
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMrr NO.
10100 MARY AVE
BURKETT'S POOL PLASTER INC.1
1
:
S A CONTROL NO.
(209)529-6944
ARCHITECrfENGINEER: -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Businesz and Professions Code, and my license is
in full force and erfee ( r
REPLSTR POOL # 1 & # 5 RE —TILE # 1 &# 5 , INSTL NEW
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Dice — 2—J O Contractor .:'' S on1 �%f
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ARCHrrECT'SDECLARA71ON
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I understand my plans shall used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
l hereby affirm that 1 am exempt from the Contractors Liccnse Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, nr repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
2 5 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
net mere than five hundred dollars (S500).
3 2 6 2 7 0 0 3.00
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and the structure is notintended or offered forsale (Sec.7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such pmjects with a comractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B & P C for this mason
Owner Date
'•
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to selr-insure for Workers Compen-
sation, as provided far by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
WORKERS'
COMPENSATION INSURANCE
(ibis section need not be completed it the permit is far one hundred dollars ($I00)
or less)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of Caliramia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate or Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Codc, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance or
the work fur which this permit is issued (Sec. 3097, Civ. C)
-
Landers Name
,
Lenders Address
I certiry that I have read this application and state that the above information is
"
correct. i agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City or Cupertino against
liabilities,judgm nts, costs and expenses which may in anyway accrue against said City
' in consequent the gmntin of this permit.
Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes �RNo
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
. all new materials for Inspection.
District? i
❑ Yes %6No
t
1 have read the hazardous materials requirements undcrChapter6.95 of the Califor-
nia Health &Safety Code, Sections 25505, 25533 and 25334,1 understand that if the building
does not suers y have nt, that it is my resprruihility a notify the occupant of the
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