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09050079 CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 1658 JAMESTOWN DR A TO Z POOL T) SPA RRPATR ngnSQ079 OWNER'S NAME: PERMIT ISSUE DATE AO A O. CONTROL NO. 408) 374-6268 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u p O LICENSED CONTRACTOR'S DECLARATION Job Description U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is o y in full force and e fl ty�j g POOL DEMO ? Licensc Clasa n —2; Date >✓ �_Contractor �r!/Pi�> lv.•� ARCHITECTS DECLARATION 1 understand my plans shall be used as public records DyU 4 O y Licensed Professional y OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractors License Law for the p O following reason.(Section 7031.5,Business and Professions Calc:Any city or county ywhich requires a permit to construct,alter,improve,demolish,or repair any structure _ prior to its issuance,also requires the applicant for such permit to Glc a signed statement z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation y (commencing with Section 7000)of Division 3 of the Business and Professions Cate)or 0 y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type net more than five hundred dollars(5500). 3 6 6 10 0 E 3 . 01 ❑I,as owner of the property,or my employees with wages as their sole compensation, will do the work.and the structure is not intended or offered for sale(See.7044,Business Required Inspections and Professions Code:The Conuactoes License Law does not apply to an owner of q P 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 docs not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt under See. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure for Worker's Compan- ion,u provided for by Section 3700 of the Labor Code,for the performance of the wrack for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workees Compensation Insurance carrier and Policy number am: Cartier Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so to become sub eft to the Workers'Compensation Laws of California.Dau Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z 2 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of GY, the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lendces Name Lender's Address U 0 1 certify that I have read this application and state that the above information is 4.n"c correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building consuucdon,and hereby authorize representatives of this city to enter upon the a above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against tom„ liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. Date "-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b): SOURCEULATIONS. _7-111 '2 r--' s- V e' Re-roofs c� Signature of Applicant/Contractor Date r HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Mi7ldc.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. C]Yes If a roof Will the applicant or future building occupant use equipment or devices which ,s installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes ®'N0 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements hich must be met prior w T !fa Ccr ificate of Occupancy. Signature of Applicant Date All roof coverings to be Class'``or better Owner or authorized agent Date CITY OF CUPERTINO MEMO CUPE(�TINO PERMIT APPLICATION FORM a9�s���� APN# A) Date: ` Building Address: c/ Sd -C j oto vl� Mailing Address (if different from building address): Owner's Name: ' _ 5� ,� Phone: Contractor: Phone Fax: 7 z. c ��90 Contractor License #: 7:PX r7 Cupertino Business License #: Contact: Phone: �r-P o 12;r�y Fax: Residential [ Sq Footage Commercial ❑ Sq Footage Job Description: Valuation: s�z� Project Size: Express Ef Standard ❑ Large ❑ Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residential B 1SFDWL-DEM 1DEMOPRES Pool Deno Residential B 1SFP00L-DEM_ / 1BCBSC Cal Bld;; Standards B ALL PERMIT Commission Fee TYPES l 1BSEISMICRE Seismic Residential B Revised 01/07/09