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CITY OF CUPERTINO
BUILDING DIVISION ]P][1'RMIT
BI,IIIJaIN91DRF,SS N I PER CT
SWAN POOLS
PERMIT NO. 03040095
'
1495 S WINCHESTER BLV
"L idr7t17/2003
PHONE:
(408) 866-6893
SANITARY NO. CONTROL NO.
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB0 MECH
0 0 0
LICENSED CONTRACT'OR'S DECLARATION
1 hereby 1 Chapter 9
Job Description
affirm that am licensed under provisions of (commencing
with Sectiona�7��0QW) of Division 3 of the Business and Prgt ssiuns Code, and my license is
LicenseClass/ GL�'1� Lic.N
INSTALL POOL & SPA
•XV--e-
Dates, Contractor
_X ARCHITECTS DECLAK' 1
1 understand my plans shall he used as public rLWrds
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Codc: Any city or county
which requires a permit to concoct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License law (Chaptcr9
Sq. Ft. Floor Area
$ 2 ��I bion
(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
3 4D ®iQ1lT 0 0
`.?
Occupancy
P Y T YPe
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
103 - UFER Required Inspections
Q p
will do the work and the structure is not intended or offered forsale(Sec.7044.Business
and Professions Code: The Contractor's License Law does to
not apply an owner of
property who builds or improves thereon, and who does such work himselfor through his
104 — REBAR
own employees, provided that such improvements are not intended oroffered for sale. If,
107 - POOL /BONDING
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
301 — ROUGH PLUMBING
sale.).
304 — ROUGH ELECTRICAL
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
concoct the project (Sec. 7044. Business and Professions code:) The Contractors Li-
502 — FINAL PLUMBING ENERGY
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
503 — FINAL MECHANICAL ENERGY
License Taco.
506 — GAS TEST
❑ 1 am exempt under Sec. B & P C for this reason
510 — FINAL PLANNING
Owner Date
511 — FINAL POOL
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
516 — F I NAL BUILDING
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3710 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Inscanis and Polic
(urance
jigbere:
`SI 576- 1AaV1lA Polity o.: 8
ov
CERTIFICATE OFEXEMPf70 OMWORKERS'
COMPENSATION -INSURANCE
(This section need not be completed if the permit is forone hundred dollars (SIO(1)
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 as to become subject to the Workers Compensation
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 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 of
' the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
1 certify that 1 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
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 may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AIYD WILL COMPLY WITH ALL NON -POINT
Issued by: Date I
U
Re -roofs
Type of Roof
n i
pplicanUCo ct Date
H DOUS MATERIALS DISCLOS E
Signatur�d,
e applic or future building occupant store orhandle hazardousmaterial
as defineby the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cade. Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Ycs fg'(Ju
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 No
I have read the hazy sus materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 unders=d that if the building
docs not currently have a tenant. that it is my resportsihility to nodl'y the occupant Of the
req 'rementswhi tbemet p' r cc of aCcrtificatc fOccupancy.
Signature of Applicant Date
1-1 -Lit
-All roof coverings to be Class "B" or better
ner or B&rized ager ate