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12040014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21975 SAN FERNANDO AVE CONTRACTOR:PI 1ILLIP D.f3JURMAN PERMIT NO: 12040014 OWNER'S NAME: TSAI CI IIA-JEN AND LIN MIAO-YING 1250 IIIG11\VY 101 DATE ISSUED:04/03/2012 OWNER'S PHONE: 4082340286 AROMAS,CA 95004 PHONE NO:(650)904753.1 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class_ Lic.H 7(o z / r r r MECH RESIDENTIAL COMMERCIAL Contractor� Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE GUNITE SWIMMING POOL(450SQFT) (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 perfommance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5000 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number:35710006.00 Oceupaney Type: APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above i formation 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, 18U 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 121.3-49 with all non-point source regulations per the Cupertino Municipal Code.Section 9.18. Issued by:g��AN ��TG� Date: avav ^ /y Signature Date RF.-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material beug installed-If a roof is installed without first obtaining an inspection,I agree to remove all new materials for hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,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.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALI-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 ILA-LARDOUS 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 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 the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth& performance of the work for which this permit is issued. Safety Code,Section 25532(s)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 1 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 authorized agent: Compensation laws of California If,after making this certificate of exemption,I Date:_ become subject to the Workers 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 afhrn 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 stale 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 I'or inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION 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 Dale City of Cupertino RFcF,1vEI)) APR 0 3 2012 /2�iy/o✓� `>'SD Ste. �;• BY: �7vry/Tim �tt/im�i✓✓�7 ap Labels Abc Street Names Secondary Address Labels Primary Address Labels Freeway _ r, Basemap Street Centerline'" a County Major Roads 2197 County Freeways Right-of-Way v� .�cl\/ \✓ r� t Parcels • ;r •i ,{�t -� ., -;to g' X' � Community Development ' ® City Boundary °�'��:' �y\Vl ✓ r7 ,,- ® Aerials-April 2011 ' ' a 1�l�;•s DuL nor•, ChipSer\ 2-�Li — v1 Flog' 3�� ;'� rr ?' e �o• A (: 3,�7. /Q . COMMUNITY DEVELOPMENT DEPARTMENT N SCALE 1 :417 BUILDING DIVISION-CUPERTINO ro N � APPROVED �\ 20 0 20 40 so FEET This set of plans and specifications MUST be kept at the Job site during construction. It is unlawful to make any changes or alterations on same,or to deviate therefrom,without approval from the Building Official. The stamping of this plan and specifications SHALL NOT be held to perms or to be an approval of the violation OP of any provisions of any City Ordinance or State Law. BY l�4/✓ �IAiG� OFFIG"E CDATE `/•3•/� PERMIT NO. hftp://gissvr/cupertinointranetthome/mapFile.aspx Tuesday, April 03, 2012 10:53 AM CITY 'OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: ' Rng: Sub: Blk: Lot: APN . . . . . . . . : 35710006.00 DATE,- ISSUED. . . . . . . 04/03/2012 RECEIPT .#. . . . . . . . . BS000016439 ( REFERENCE ID # . . . : 12040014 SITE 'ADDRESS . . . . . : 21975 SAN FERNANDO AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER TSAI CHIA-JEN AND LIN MIAO-YIN ADDRESS . . . . . . . . . . : 21975 SAN FERNANDO AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PHILLIP D BJURMAN 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 5, 000. 00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 5, 000. 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 ----------------- --------------- -------------------- CHECK 301.50 #6012 --------------- TOTAL 'RECEIPT 301.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO CITY OF CUPERTINO D FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21975 San Fernando DATE: 04/03/2012 REVIEWED BY: Sean APN: BP#: 'VALUATION: $5,000 *PERMIT TYPE: Demolition Permit P/-4,,v Cil/(c'K 7)TE. PRIMARY Swimming Pool, Res. PENTAMATION 1SFP00LDEM USE: PERMIT TYPE: WORK Remove ounite swimming pool 450 sq ft SCOPE FEE ID #POOLS iDEMOPRES 1 ]Itch. flan r'hre6 /'Gunk. l'lun(.'hcrk !Ck•.:. Thin CGrck ,11,,:h. l'.•Pnrit Fv'c /'/mol,_Pooani/i ha.r.IAv',lir I Ofdrr Ilrrh. Imp. Orhrr Pluni4 Insp. Ow, h.o. Iny,. ,1-!,,h. In•p. li,;: l'huuh. Gnp. Fre tiler. lap. /,c NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the relimina information available and are only an estimate. Contact the De t or addn7 info. FEE ITEMS (Fee Resolution 11-053 E!/.' 7///l 1) FEE QTY/FEE MISC ITEMS Mon Chcc/` Fee. SlIppl. l'C 1''e,r l'hnnh,/:1-ler.2%litre Permit Fee: $300.00 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 l'hmlh.%ahah./litre l'crniil Frc: Ci�nsn urlion Tui: ;I dbninisn olil r /y(- 11 err11...k 11'ilhow Pal'Inil:� Adl"11)r01 l'lmurin,t I-ev.s: T 71 lfloval0ociomurlolion Fres: A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Sids Commission Fee: IBCBSC $1.00 SUBTOTALS: $301.50 $0.00 TOTAL FEE: $301.50 Revised: 1/19/2012 SWIMMING(�6'OLI SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333 •building(cDcuoertino.orQ CUPERTINO �lalLlrp D 3j :Ar,-r-.iaJ PROJECT ADDRESS APN d (D S ,moi✓ nl'Do ✓c OWNERN • HONE E+HALL L Yo2l STREET ADDRESS CRY, STATE,ZIP FAX 'IQfncr+.l o � C ti t n.+ CONTACT NAMs-� '� PHONE E-MAIL YI.A,t6-1' 7t • �' 11., -L) - mal c.--) f 3� STREET ADDRESS CRY. ATE• ZIP FAX 1 1S6 F-1IC14 of ��,�// • c 9 11OwNER C3O"ER-BUILDER 11OWNER AGENT ASN CTOR ❑CONiAnC[OR AGE T ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT C 141CTORNAME LICENSE NUMBER LICENSETYPE BUS.LICE L1 { 7• v.�M a-� C��p ANY NAME . E-MAIL FAX tS v- STREET ADDRESS CRY STATE,ZIP PHONE .a.vl/d It'Sc.� LA ARCHMCT/ENGINEER N NE LICENSE NUMBER BUS.LIC a COWA,NY NAME E-MAIL FAX STREET ADDRESS _. CRY.STATE,ZIP PHONE DESCRIPTION OF WORK USE OF XY, SFD or Duplex ❑ Multi-Family TYPE MATERLV-TYPE(CODE) AREA (SQ.FT.) / VALUATION(s) STRUCTURE: (❑ Commercial POOL �'VN/TC y5 D •�UO(� POOLISPA MATERIAL TYPE CODES: SPA V - VINVL-LINED F - FIBERGLASS DEMO �j GUNITE � P PREFABRICATED AECELBYYx tI`� c TOTAL VALUATION - /��� _ - xr$n�.`,�'X'���' �./'/I��.t f�--i•_=a-``-� .i'.-`moi`��. U� 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 1 have provided is correct I have read the Description of Work and verify it is accurate. I agree In comply with all applicable local ordinances and state laws relatin 'd' mtrucdon utho=representatives of Cupertino to enter the above-identified property for inspection purposes. Signatureof ApplicanVAgent ( Date: 2— SUPPLEMENTAL INFORMATION REQUIRED "=�'w roknce'�.usEoen.Y ,n • :�-$, �.ti 0 _Commercial or Multi-Family Buildings with Public Swimming Pools: f ..�� i ?�'. �.,.�r,* Department of Environmental Health approval required. r. ovER TeonvTB BnanmGne �y. r- E E>sRBss�t-"`?.crF� �C1�PtTureRT.vGPBPr�'�;t-i�Fc,.�u.�i� .'�SFANnkRb^-C' �� ��a¢ © PDBLICiwORKS-DEVT ,� _ L �( CLYDtON'Y�`I.TALID•JtaTH DIS Q'wMaaoB.'::x w Tse.N (�snmrxrtssEwERTma SwimPoo1App201 I doc revised 03/16/11