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04080206 VOIDa(114 CITY OF CUPEKrINO CITY OF CUPERTINO fi PERMIT APPLICATION FORM APN # 7 ate:1Z Date://1Z Building Address. � f< -Ys- i Owner' ame: Phone 9: Contr tor: Phoae:- q 0y, 3-1 t (.qo License #: Q!, s3 ContagY; eA Kn— Phone•, Cupertino Business License Building Permit Info: Bldg El Job Description,— VK I/K / Residential—K CdYnmercial E] Cost of Proj 7", if ,Yppli ' ble Fee ID Fee Description Fee Group BSWIM Swimming Pool BUILDING BUSLIC Business License BUILDING 3 CITY OF CUPERTINO BUILDING DIVISION PE] [Z CONTIUCTOR IN)" PION. BUILDING ADDRESS: LEWIS POOLS PERMIT NO04080206 OWNER'S NAME: MARK qANTnpn 160 CR-12TICH LN PERMIT ISSUE DATE PHONE: SANITARY O. CONTROL NO. ARCH ITECTIENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business an Prucssiuns Code, and my license is infull force lch.�- OS�, License ClazsLic. p SWIMMING POOL Date ContractorV z',` ARCHITECTS DELI -ARA ION 1 understand my plans shall he used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License 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, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 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 not more than rive hundred dollars ($500). ❑ 1, as owner of the property. or my employees with wages as their sole compensation, Re uiredlns eetions will do the work, and the structure isnot intended oroffered for sale (Sec.7044,Business625017.00 and Professions Code: The Contractors License Law does not apply to an owner of q p property who builds or improves thereon, and who docs such work himself or through his own employees, provided that such improvements are not intended or offered forsale. 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 projects with a contractor(s) licensed pursuant to the Contractor's License taw, ❑ I am exempt under Sec. . B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Worker'sCompen- sation, as provided for 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 3700 of the Labor Code, for the performance of the work for which this permit is issued. My WorY,ey's Com)fnnsauon Insurance carrier and Policy r Carried/ a U h• 1 h� Policy No. 7 G C �� CERTIFICATE OF EXEMPTION FROM WORKERS' _ COMPENSATION INSURANCE (This section need not be com pleted if the permit is for one hundred dollars ($10(7) or less.) 1 certify that in the performance of the work for which this permit is issued. I shall not em"ploy any person in any mannerso as to become subject to the Workcrs' Comperuatron Laws of California. Date 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 forthwith comply with such provisions or this permit shall be deemed mvoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ('or the -performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to cpmply with all city and county ordinances and state laws relating to building consuuctiorj, and hereby authorize representatives of this city to enter upon the shove -mentioned property for inspection purposes. (We) agreezto save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequ nt:5, the granting of this rm pei APPLICAN UNDERSTANDS AND ILL COMPLY WITH ALL NON -POINT Issued by: Date SOURC EGULATIONS. ti 0/ p Re -roofs Signature of ApplicanUContractor 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 O°"- 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? " • ❑ Yes / I 1—,> s' I have read the hLclous materials requirements under Chapter 6.95 of the Califor- nia Hcahh&S ety¢ode, Sections 25505.2P3fiand25534.1understand that ifthe building docs not current. ; asc a tenant, that 4is/rny responsibility to notify the occupant of the rcyuircmcn�tyW�iicnln'ustjbje me/jstz eanSm6fa Lrt;eeate dfaenpancy. priors Signature of Applicant Date All roof coverings to be Class "B" or better Owncr or authorized agent Date f CITY OF CUPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: �� r 1--/0<61 L,4Ne- PERM T # Oq , c2 b OWNER'S NAME:�(kuK X)CrZK6 PHONE # GENERAL CONTRACTOR: Oj /S F, -C - L F 0- 3-11 S I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: n Contractor Signature Dae SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank She et S eet R ck T n Contractor Signature Dae