12050020 CITY OF CUPERTINO BUILDING PERMIT
BIILDINGADDRF.SS: 21(A2COLUMBUSAVE CONTRACTOR:CIiANG11AS1-IANN AND PF.RMITNO: 12050020
CHIU SHUWEN TRUS
OWNER'S NAME:
CUPERTINO.CA 95061 PRONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q
M ECH r RESIDENTIAL r COMMERCIAL
Contractor Date
1 hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: DEMOLITION OI'IN-GROUND SWIMMING 1'OOLU50
(commencing with Section 7000)of Division 3 of the Business&Professions SQFf)
Code and that my license is in full force and effect.
1 hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a cenif icale of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ollhe work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valualion:$1200
Section 3700 of the Labor Code,for the performance of the work for which this
pemtit is issued.
APN Number:3561 RO50.00 Occupancy'Type:
APPLICANT CERTIFICATION
I certify that I have read this application and slate 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 properly for inspection purposes. (We)agree to save
indemnify and keep hamilessthe City ofCupertino 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 ofthis pemtit. Additionally,the applicant understands and will comply
With all nun-point source regulaiiats per the Cupertino Municipal Code,Section
9.18. Issued by: / Dale:
Signature Dale
❑ OWNER-RUILDF.R DECLARATION RE:ROOFS:
All roofs shall be inspected prior to any tooling material berg installed.If a roof is
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[heir 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(See.7044.Business&Professions Code). AL1,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 Ccr[ilicatc 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, 1 will maintain
perfomtance ofthe 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(x)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 Qualitv 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 die work for which this permit is issued,I shall Ilealth&Safely Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensationlawsof California. IL after making this certificate of exemption.I Owner uthorize g h:
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 AGF.NCV
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agencyfor 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 1 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,
costs,and expenses which may accrue against said City in consequence of the
granting of Otis pemtit.Additionally,the applicant understands and will comply ARCIRTF.Cf'S DECLARATION
with all non-point source regulati 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
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21642 Columbus Ave DATE: 05/02/2012 7 REVIEWED BY: Sean
APN; BP#: 'VALUATION: $1,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration I Repair
PRIMARY SFD or Duplex PENTAMATION 1SFP00LDEM
USE: PERMIT TYPE:
WORK Demolition of in round swimming pool.
SCOPE
.11rclr. flan Check Plumb. Plan Check E/ec. Plan Clmrk
M'.01 I'.•rmil Fee: Plumb. Pennie Fee: litre. Permil hied:
Orlmr Mrch. Imp. Other/'limb In.cp. Other Tiler.Gasp.
.Pkch. /rap. Fcr: P/umb. Insp. Fre: Elm Grip. Frc:
NOTE: This estimate does not includejees due to other Departments(Le Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelimina information available and are only an estimate Contact the Dept for addn'l info,
FEE ITEMS (Fee Resolution 11-053 E(C 7/1111) FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 = # Swimming Pool
Suppl. PC Fee: Q Reg. 0 OT FO.OThrs $0.00 $300.00 IDEMOPRES I Demolition
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Cortalrurlion Tera':
Admiuisi ruive Fee: O
Work Without Permit? Yes (E) No $0.00 (F)
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Building or Structure t�
Travc1 Dociolum nlion Fees: A
Strom, Motion Fee: IBSE/SM/CR $0.501 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.001 1
SUBTOTALS: $1.501 $300.001 TOTAL FEE: $301.50
Revised: 04/01/2012