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12020029 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10791 BROOKWELL DR CONTRACTOR:PHILLIP D.BJURMAN PERMIT NO: 1/2020029 OWNER'S NAME: BRADBURY GREG 1250 HIGHWY 101 DATE ISSUED:02/07/2012 OWNER'S PHONE: 4084644991 AROMAS,CA 95004 PHONE NO:(650)906-7533 13 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ' ELECT PLUMB License Class Lic.# L 2S d MECH RESIDENTIAL COMMERCIAL ' Contractor - Date - I hereby affirin that I am licensed under the provisions of hapten 9 JOB DESCRIPTION:DEMO POOL FOR SINGLE FAMILY RESIDENCE(500SQFT) (commencing with Section"000)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 tbr Worker's Compensation,as provided for by Section 3''700 of the Labor Code,for the performance of the work tbr which this permit is issued. Sq.Ft Floor Area: Valuation:$6000 1 have and will maintain Worker's Compensation Insurance,as,provided for by Section 3700 of the Labor Code,for the pert6miance of the work for which this permit is issued. APN Number:36921015.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for Inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnity 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 the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date: 9.18. 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,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole.compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7 044, Business&Professions Code) 1,as,owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have,and will maintain a Certificate of Consent toself insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,ass provided for by Section-3)700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this pert-nit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as,provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the P ermit is Issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so is to become subject to the,Worker's 11 authorized agent: C ompensation laws of California. If,after making this certificate of exemption, "tz2-- Date: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 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 that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date C, I I CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36921015. 00 DATE ISSUED. . . . . . . : 02/07/2012 RECEIPT #. . . . . . . . . : BS000015951 REFERENCE ID # . . . : 12020029 SITE ADDRESS . . . . . : 10791 BROOKWELL DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BRADBURY GREG ADDRESS . . . . . . . . . . : 10791 BROOKWELL DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PHILLIP D BJUR14AN CONTRACTOR . . . . . . . : PHILLIP D. BJURMAN LIC # 23653 COMPANY . . . . . . . . . . : PHILLIP D. BJURMAN ADDRESS . . . . . . . . . . : 1250 HIGHWY 101 CITY/STATE/ZIP . . . : AROMAS, CA 95004 TELEPHONE . . . . . . . . : (650) 906-7533 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 6, 000 .00 1.00 0.00 1.00 0 .00 1BSEISMICR VALUATION 6, 000 .00 0 .60 0.00 0 .60 0.00 1DEMOPRE EACH 1.00 300.00 0. 00 300 .00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 301.60 0. 00 301.60 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 301.60 VISA --------------- TOTAL RECEIPT 301.60 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO CITY OF CUPERTINO 3 FEE ESTIMATOR-BUILDING DIVISION REVIEWED BY: bob s. SS: 10791 brookwell DATE: 02/07/2012 ADDRESS: "VALUATION: [—$6,000 APN: j BP#: PERMIT TYPE: Demolition Permit PENTAMATION PRIMARY lSFPOOLDEM USE: Swimming Pool, Res. PERMIT TYPE: WORK demo pool for sfd residence SCOPE FEE ID FLR AREA s 1DEMOPRES ii I A NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public fVorks,Fire,Sanitary Sewer District,School District,etc.). These Lees are based on the-erefininaa inforination available and are onl an estimate. Contact the Dfgt-Lor addn'li2L& FEE ITEMS 0.'°ee `yes Oly""-'(),-yz 1 1-0-53 Ef FEE QTY/FEE MISC ITEMS Permit Fee: $300.00 SUPPI. Insp. Fee: Reg. C OT 0.0 hrs $0.00 A �, c4"c',-ri Fee: 1BSEL5A11C-'R $0.60 Select an Administrative Item IBCBSC $1.00 C SUBTOTALS: $301.601 $0.00 TOTAL FEE: $30 _60J Revised: 1/19/2012 SWIMMING POOL I SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•buildinQC�cupertino.org CUPER7'INO PROJECT 5_• �- - APN# _36- r 4�24 OWNER NAME --� HO E-MAIL STREET ADDRESS CITY, sT,9r�FzIP � I FAx CONTACT NAME, • E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR 13CONTRACTOR AGENT C1ARCHITECT 11ENGINEER ❑ DEVELOPER C1 TENANT CO a?Rjr,�� LICE NUNIBER LICENSE rof, BUS.LIC# e . C ANY N E E-MAIL FAX S ET ADDRESS CITY,ST TE ZIP /� G; `_.l P ,% � ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK ) 6 USE OF or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S) STRUCTURE: ❑ Commercial POOL ."IV\ P SPA E CODES: SPA V - VINYL-LINED F - FIBERGLASS DEMO G - GUNITE NO" � T NP - PREFABRICATED ,4�I,L}JAT�Op3lyt x x ,, r`.."ryac�, # f i r f •�. '' �J`.' TO V 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 have read this application and the information I have rovided 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 relatin it truciQn.l rize representatives of Cupertino to enter the aboverident' ed property for inspection purposes. f � Signature of Applicant/Agent: -4-ADate - . xY' : .rr i� z&S'�A•7,xz-.�z;�'�tt` X��m •_ �''"�'�m` - SUPPLEMENTAL INFORMATION RE D g` '` v,- e::i.� ��`•..5�i�iCRia�[i�W��F4�iF�txk:�t ��'a u �*a^";.'.'... �'_S. i.�.= Commercial or Multi-Family Buildings with Public Swimming Pools: f- Department of Environmental Health approval required. x .. ..•,: _,tom •. < -. �-:'of'�-eaX'Y .s it .s �g •:sxx,3"'''e "-x"'A 1- £' 3' r^r y�°` z.s' a`,,Y °iy'Y_3',r i'.+- SwimPoolApp 2011.doc revised 03/16/11