B-2016-1679 - PERMIT & APPCITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1679
22080 WALLACE DR CUPERTINO, CA 95014-0128 (326 03 039)
LIFETIME POOLS INC
PALO ALTO, CA 94303
OWNER'S NAME: ZAMIR ITAMAR AND SHIRY
DATE ISSUED; 04104/2016
OWNER'S PHONE: 408-654-9084
PHONE NO: (650) 494.7070
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class SWIMMING POOL Lic. # 2? 0382
Contractor LIFETIME POOLS INC Date 02/28/2017
X BLDG —ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under fire provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & A ofessions Code and that my
license is in full force and effect
JOB DESCRIPTION:
INSTALL (N) IN -GROUND GUNITE SPA (88 S.F.)
I hereby affirm trader penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
-
perfma ornce of the work for which this permit is issued.
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have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. h't Floor Area:
Valuation: $30000.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
—
information is correct. I agree to comply with all city and county ordinances
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
32603 039
representatives of this city to enter upon the above mentioned property for
inspection purposes, (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations err the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM C�AAA` ,EIfI�SP- TION.
Signature Date 04/0412016
Issued by: MELISSA NA '
Date: 04/04/201
OWNER -BUILDER DECLARATION
I herby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection, 1 agree to remove all new materials for
compensation, will do the work, and the an uctut'e is not intended or offered for
inspection.
sale (Scc.7044, Business & Professions Code)
z. 1, as owner of the property, am exclusively contracting with licensed
Signahne of Appliceun:
contractors to construct the project (Sce.7044, Business & Professions Code).
Date: 04/04/2016
I hereby affirm under penalty of perjury one of the following three dechu'atlmms:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1 have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of die work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
x. I have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous mate fats requirements under Chapter 6.95 of the
Section 3700 of the Labor Code, for lire performance of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued.
maintain compliance with the Cuperfino Municipal Code, Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
motor Jai. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defnned by the &ry Area Air Quality Management District I
Worker's Compensation laws of California. If, after snaking this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety r e, ctions 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such to or this permit shall
be doomed revoked.
Owner or authorized agent:
APPLCANT CERTIFICATION
Date: 04/04/2016
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Cie C.)
to enter upon the above mentioned property for inspection purposes. (We) agree
Lenders Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 04/0412016
Professional
CUPERTINO
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinpCr�Cupertino.org
3-Z616-1��9
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DESCRIPTION OF WORK
USE OF ❑ SFD or Duplex ❑ Multi -Family
TYPE
MATERIAL'FYPE (CODE)
AREA (So FT.)
VALUATION (S)
S'rRUCI'URF.: ❑ Commercial
POOL
POOLISPA MATERIAL TYPE CODES:
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P - PREFABRICATED
By my signature below, Ioertify to each of [he following,
I am tlhe pr elty ow thorized vent to act the property owner's beha have reed this
application and the information I have provided is correct.
i have read the Descnption of W and veril' is accurate. I agree to comply with II applicable local
ordinances and state laws relating to lau g ons 'tenon.
I authorize representatives of uperti enter the above -identified property for inspection purposes.
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Signature of Applicant/Agent:
Date: V
SUPPLEMENTAL INFORMATION REQUIRED»,
_ oFElce
oscoNlY
PLAN CHECKTYPE?
ROII'I ING SLIP
Commercial or Multi -Family Buildings with Public Swimming Pools:
_
Department of Environmental Health approval required.
'EB-THE coulvrERUILDING
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PI.AN'NINGDEPT
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❑ PUBLIC WORKS DEPT
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❑ EN\NRONMENTALHEALTH
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❑ SANITARYSCSYER DISI RIOT ,
SmimPoolApp 20H.docrevised03/I0111