12010016 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10318 COLD HARBOR AVE CONTRACTOR:' PERMIT NO: 12010016
OWNER'S NAME: HOLLAND ANTHONY R AND KATHEY LOUISE �(S3.31�� ' DATE ISSUED:01/03/2012
OWNER'S PHONE: 6502243722 , r PHONE NO:
G LICENSED CONTRACTOR'S DECLARATION t
BUILDING PERMIT AO: BLDG ELECT PLUMB
License Class Z—? Lic.# 7) V �
MECH RESIDENTIAL COMMERCIAL
Contractor—,d Date ! 3^ 13
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RESIDENTIAL POOL DEMOLITIION(1200SQFT)
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$4600
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36909031.00 Occupancy Type:
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 and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued Date:
Signature Date 7 — L
C OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or aorize a nt: Z
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked. /�Xx
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
c(--`, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
I ig of this permit.Additionally,the applicant understands and will comply
wig,.all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36909031. 00
DATE ISSUED. . . . . . . : 01/03/2012
RECEIPT #. . . . . . . . . BS000015650
REFERENCE ID # . . . : 12010016
SITE ADDRESS . . . . . : 10318 COLD HARBOR AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : HOLLAND ANTHONY R AND KATHEY L
ADDRESS . . . . . . . . . . : 10318 COLD HARBOR AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : FOUR SEASONS GARDEN
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 4,600.00 1. 00 0.00 1.00 0. 00
1BSEISMICR VALUATION 4, 600 .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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• building(acupertino.org
CUPERTINO
PROJECT ADDRESS to� � � >Zi TA7PN7# 1 q �J
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OWNER NAME 1 [ , PHONE E-MAIL
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STREET ADDRESS CITY, STATE,ZIP FAX
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CONTACT NAME P�O� ^� E-
STREET ADDRESS L y t� C1TY,STS, ZIP FAX
IES, S i
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT A CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENS NUMBER q��- LICENSE TYPE BUS.LIC 4
i 'Y1,A.. e L.
COMPANtlikME EM, y FAX � �j �
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STREET ADDRESS CITY,STATE,ZIP PHO
.71
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK / P - l
USE OF or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S)
STRUCTURE: ❑ Commercial
POOL
POOUSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO
G GUNITE
P - PREFABRICATED -.��
REL &S� Ile,4
Al
TOTAL/ UA /OjV�}
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I h2ve read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED w ry eV,WISH '
. ._
Commercial or Multi-Family Buildings with Public Swimming Pools: w
Department of Environmental Health approval required.
c x W.
�Y1�11T�4ItY SS�S+EI817Lf�'1€RI� �=- ::=
SwimPoolApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10318 cold harbor dr. DATE: 01/03/2012 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: 1$4,600
y PERMIT TYPE: Demolition Permit -
PRIMARY Swimming Pool, Res. PENTAMATION 1SFPOOLDEM
USE: PERMIT TYPE:
WORK pool demo residential
SCOPE
FEE ID FLR AREA
s.f.
1DEMOPRES 1
. ...... Li
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the relinina in ormation available and are only an estimate. Contact the Det or addn 7 info.
FEE ITEMS (Fee Resolution 11-053 Elf 7'1/11) FEE QTY/FEE MISC ITEMS
-F
Permit Fee: $300.00
Supp/.Insp. Fee Reg. Q O-70-OT. hrs $0.00
Strona,/Motion Fee: $0.00 Select an Administrative Item
BldgStds Commission Fee: IBCBSC $1.00
SUBTOTALS: $301.001 $0.00 TOTAL FEE: $301.00
Revised: 12/04/2011
NT
PM
DFPARTM
COMMUNITY
G UV SO(ONECUPERT NO ENT
AppR.OVED
This set of plans and specifications MUST be kept at the
job site during construction. It is unlawful to mawe any
IV ci,ar;q�3s or alterations from the Buildingdeviate
O'ficial.
therefrom,without app
rvals .n,e,:;t:�rppjrla of this plan and specifications SHALL NOT
P he;d(o P()M It or tote an approval of the vi:;tat on
O, -,y prc,visions of any City Ordinance or Stare Law.
BY_.. --- �� ► —
PEFJe4! NO.
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