12030073 CITY OF CUPERTINO BUILDING PERMIT
BUIL1/1NGADDRESS: I4611AMESTOWNDR CONTRACTOR:GONZALO QUI ROZ PERMIT NO: 12030073
CONCRETE
OWNER'S NAIVE: KISHORE PANKAJ AND SANGEEfA 84 EL CAMPO DR DATE I.SSl1ED:03/152012
OWNER'S PHONE: 6093560121 SAN JOSE,CA 95127 PHONE NO:(41181464-74"
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT r__, PLUMB r
License ClassLie.p_ZD L` [ r r'
/) / 11IECH RESIDENTIAL COMMERCIAL
Contractor ( .2n)2?_we lD Date031 t Z
1 hereby affirm iliac 1 am licensed under lite provisions of Chapter 9 306 DESCRIPTION:SWIMMING POOL DEMO(600SQFI)
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect
1 hereby affirm tinder penalty of perjury one of the following two declarations:
I have and will maintain a cenifleme of mnseut to self-insure for Worker's
Compensation,as provided for by Section 3700 of the labor Code•rix the
perfommnce oI'the work for which this permit is issued.
I have and will main am Worker's Compensation Insurance,as provided for by Sq.Pt Floor Area:
Valuation:&4500
Section 3700 of rhe Labor Code.for the performance curdle work for which this
permit is issued. APN Number:36610080.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application mid state that the above infonnation is
correct.I agree to comply with all city and county ordinances and stale laws relating PERMIT EXPIRES [F WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property lir inspection purposes. (We)agree to save WITHIN t80 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of rhe
grantingofthispennit. Additionally,ttthhre applicmnunderstands mid will comply
with all non-point source n is the Cupertino Municipal Code.Section Issued by _ Date: �,/
�
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,(agree to remove all new materials for
1 hereby affirm that 1 one exempt from(lie Contractor's License Law for one of inspection.
the following two reasons:
L as owner of the property,or niy employees with wages as their sole compensation. Signature of Applicant: Date:
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETFER
construct the project(Sec.7044,Business R Professions Code).
1 hereby affirm tinder penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have readthe hazardous materials requirements under Chapter6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505.25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of lite Labor Code,for the compliance"illi the Cupertino Municipal Code,Chapter 9.12 and the Health&
perfommnce of the work for which this permit is issued. Safety Code.Section 25532(a)ahould I store ar handle hamrdous material.
I have and will maintain Worker's Compensation Insurance,as provided fir by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of rhe Labor Code,for the perfarnance of die work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued, Health&Safety Co .ections 255415,25533,and 25534.
I certify than in the perform:ulce of the worrk fair which this permit is issued,I shall
not employ any person in any manner so as to beanne subjecfto the Worker's O eer a mrized agent:
Compensation laws of Cal ifomia. IL atter making this ceniticae of exeniptcn,I Date:(
Iveca a subject to the Worker's Compensation provisions of the Labor Code,I must
linhwitn coneply,with such provisions or this permit shall le deemed revoked. CONSTRUCTION LENDING AGENCI'
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify thfo
at I have read this application and state that the above inrnmion is Lender's Name
correct.I agree to comply with all city and county ordinances and sate hays relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnity and keep liamiless tee City of Cupertino against liabilities,judgments,
costs,and expenses which niay accrue against said City in consequence of the ARCHITECT'S DECLARATION
gemming of this permit.Additionally,the applicaa understands and will comply I understand my plans shall be uscdas public records.
with all non-point source regulations per the Cupertino Municipal Cole,Sectio
9.18. Licensed Professional
Signature Dame
i
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36610080 . 00
DATE ISSUED. . . . . . . : 03/16/2012
RECEIPT #. . . . . . . . . : BS000016287
REFERENCE ID # . . . : 12030073
SITE ADDRESS . . . . . : 1464 JAMESTOWN DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER . . . . . . . . . . . . : KISHORE PANKAJ AND SANGEETA
ADDRESS . . . . . . . . . . : 20 COLEBROOK CT
CITY/STATE/ZIP . . . . : PRINCETON, NJ 8540
RECEIVED FROM . . . . : GONZALO QUIROZ
CONTRACTOR . . . . . . . : GONZALO QUIROZ CONCRETE LIC # 30847
COMPANY . . . . . . . . . . : GONZALO QUIROZ CONCRETE
ADDRESS . . . . . . . . . . : 84 EL CAMPO DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95127
TELEPHONE . . . . . . . . : (408) 464-7468
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC .NEW BAL
---------- ------------ ---------- ---------- ---------- -------- ----------
1BCBSC VALUATION 4, 500 .00 1.00 0 .00 1.00 0 .00
1BSEISMICR VALUATION 4, 500 .00 0.50 0 .00 0..50 0 .00
1DEMOPRE EACH 1 .00 300 . 00 0 .00 300 .,00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 301. 50 0.00 301.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CASH 301.50
---------------
TOTAL RECEIPT 301 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 1464jamestown dr. DATE: 0 3/1 512 01 2 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $4,500
•PERPIITTYPE: Demolition Permit PLIVCHECKTFPE:
PRIMARY Swimming Pool, Res. PENTAMATION 1SFPOOLDEM
USE: PERMIT TYPE:
WORK swimminq pool demo.
SCOPE
FEE ID FLR AREA
s.f.
1DEMOPRES 1
tPeh Plan Cae k Plumb. Plan Check Flee.Plan(TccA
.Meeh.Perahir pee: Plump.Permit Fee: ec Pemuf Fee,
Other Af..'eh.hap. Other Plumb In Other h..kv..hop. Li I
lfixh.Inv!). rev Plumb./up.Fw: Fier.Imp.Fee.•
NOTE: This edimale doer not include fees due to other Departments(i.e. Planning,Public IForkr. Fire,Sanihuy Sewer District,School
District,etc.). These fees are based on the trelininanin ornwtion it ' ble and are oniv an estinmte. Contact the Deliffor addn7 info.
FEE ITEMS (Fee Resolution 11-053 EB' 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
slgghl.PC Fee
Phnnh.lAlechJFfec
Permit Fee: $300.00
SuppI. Insp. Fee-.0 Reg. Q OT 0.0 1 hrs $0.00
PltnnhJMCCh.lElee
Phtmh.,4lech.:ElecPprnhitFre:
Construction Tax:
.1,bidntsttatrre Pie:
H•brk Without Permit?
Adt•artred Planning Feer:
Travel Ductanenla ion Fees:
Strong Motion Fee: $0.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC 1.00
SUBTOTALS: $301.00 $0.001 TOTAL FEE: 1 $301.00
Revised: 1/19/2012
COMMUNITYDEVELOPMENT
DIVISION ECUPERTI O
APPROVED
� This set of plans and specifications MUST be kept at the
fob site during construction. It is unlawful to make any
o changes or alterations on same,or to deviate
tr,` fi therefrom,without approval from the Building Official.
1 The stamping of this plan and specifications SHALL NOT
Zbe held to permit or to be an approval of the violation
L` F of any'provislons of any City Ordinance or State Law_.
G�
—IcA'Z'4
� DATE
y 74 1 PERMIT NO. "
6 F- J,
T '�
0
N C t 0z'
3
0
N
�J
I �v3oc�-� 3
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
GUPERTINO (408)777-3228 • FAX(408)777-3333 •buildina(acuoertino.org
PROTECT ADDRESS APNa
'�j'L l 6 _ I (D , Q C 1
OWNER NAME ^, I"^ r 1 s PHONE DC _ 2 &NIAR.
STREET ADDRESS �Q /I•�fV'1�—I�.a.l�'��✓l-!/ ^ C�WA "I•i u 'L FAX
CONTACTNAME Y lr' PH �E E-MAIL
u CI �luclAS32-3 v
STREET ADDRESS CrTY.ST TE, ZIP FAb
3 < N�� 4Ca It2L
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHRECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CON'RACTORNAME LICENSEW, IDER LICENSETYPE BUS.LICA
CONVANY NAME /�ly, E-MAIL FAX
11+J f`6Y CbhLxt�'t.
S IFr ADDRESS �_q �..LCd. v �.' CRY.STATE,ZIP P ,N'E
ARCHrrECr/ENGINEER NAME LICENSE NUMEER BUS.LIC a
CONBANY NAME E-MAIL FAX
STREET ADDRESS CrrY.STATE,ZIP PHONE
DESCRR'ITON OF WORK
USE OF A SFD or Duplex ❑ Multi-Family TYPEMATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(1,)
mucTuu: ❑ Commercial POOL
POO VSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO
G - GUNRE J�1
a�avFlr� l lid + - TOTAL Vr
P - PREFABRICATED TRECEIVE➢.BY: � - v
ff
By my signature below,1 certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 hav read this
application and the ve e
information I have prod is covet. I have read the Description of Work and verify it is accurate. I agree t0 comply with all applicable local
ordinances and state laws relating to a. / coon. I authorize rep en[adves of Cupertino to enter the above-id tified p Try Cor inspection purposes.
Signature of ApplicanJAge 2 Date:
SUPPLEMENTAL INFORMATION REQUIRED %
^,�UyS_sE�:�O�N?L;.,Y,
_ •�.P3 TECCX TT-4a�;'L�q? ROtWri,G 5LIP+'�.' �
_Commercial or Nlulti-Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required. .�^� zC7 o TBe=cooE qC9' 'cnnWc Derr g
SQEXPRESS.- - t Q
❑ STIYUARD ®'PUBLICIVORKS DEPT
-❑t�Id RGE s❑ EWIROYIME NTA}L�I R,EALTIt
'J❑' SLtJOR. Lif: 'a e❑.S TA RR SEW'ERD STRICrF
SwimPoo[App_I011.doc revised 03/16/11