09040111 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � �� '
BUILDING ADDRESS: PERMIT NO.
10190 N FOOTHILL BLVD RAINBOV� POOLS 09040111
FERMrr ISSUE DATE
OWNER'S NAME:
QA
TnT4 ggnN lDj�rp 2 3 J A X -
S A CONTROL NO.
JNE:
(408) 836-3992
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
0 0 0
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
II hereby affirm that I am licensed under provisions of Chapter 9(commencing
U with Section 7000)of Division 3 of the Business and Pro(cssions Code,and my license is
r ym in full force and e�vt, _Z S PLT MIS DRN PER CTY HLTH DEPT (VGB)
j i2 Z License Class ate, Lic. .
C-0 Date Con
ARCHTIECTS D
1 understand my plans shall be used as public records
U.�yU
iH Licensed Professional
0 3 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
,�, which requires a permit to conswct,alter,improve,demolish,or repair any structure
4 prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
I=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $8000
J1 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 3 2 6 15 1� 5 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure isnot intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder wiB have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contrxwes Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractors
License Law.
Q I am exempt under Sec .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
wo for which this permit is issued.
and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Wor mpensatio nsurance carrier and Policy number are:
Carrier. Policy No.:
CEM3EXATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic hundred dollars($100)
Of ICSL)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any rson in any i qc ft me subject to the Workers'Compensation
Laws of alit a.Date �-/
Applic i _
NOTICE APPLIC :If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
pC .7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lender's Address
V C) I certify that I have read this application and state that tete above information is
LL�" correct l agree to comply with all city and county ordinances and state laws relating to
0 V buildinmg construction,and hereby authorize representatives of this city to enter upon the
W above- entioned property for inspection purposes
12. (We)agree to save,indemnify and keep harmless the City of Cupertino against
►F-o to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bre:
EGULATIONS.
Re-roofs -
Signature of Appli t/Contractor Dde
T Of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes j1No
Will a roof is installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
,.mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
District? ��}}
p Yes I Fits
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafelyCodc,Sections 25505,25533 and 25534.1 understand that if the building
L�or
rently have a tenant,that it is my responsibility to notify the occupant of the
requirewhich must be met prior to issuance of a Certificate of Occupancy. S lgnaturl•of Applicant Date
Ownutho gent
Da All roof coverings to be Class"� `'or better
DEPARTMENT OF ENVIRONMENTAL HEALTH
CONSUMER PROTECTION DIVISION
1555 Berger Dr.Ste 300,*San Jos6 CA 95112
C..W.f Cl.. Telephone:408 918-3400•Fax 408 258-5891
www.ehinfo.org
Plan Check Application Form
M New Owner Z Existin(i Owner
Scope of Work: El New Facility ❑ Remodel Replaster ❑ Conversion (Ex:Change in Menu)
Facility Type: EJ Restaurant Retail-- Pool El
Project Name
Current Facility Name (if any)
Street Number Directign 3treet Name
Street Type Ste #
Cross Street 0
City CUV t Zip'15 0 14 Phone# 409 93G'6Rq2
—
Contact Person (Designer/Architect/Contractor)
Business Name (if any)_� I I� 6_�
E-mail Address 2e,I ti �rLS Y44
Address i f Phone# L(OQJ 03(a 3
City State Zi S-0!9- Fax# 408—G Y
Owner of Food/Pool Operation
Phone hone #
City State Zip Fax#
Office Use Only
Comments-
Owner ID Facility ID Specialist Name
Plan Type Census City Code Submitted
Name Date
Received By
Assigned To
Amount Paid Check Number E] Stamped by City of Cupertino
AccountlD# Invoice#
Plan submitted by:n Owner❑Architect 1:1 Contractor 1:1 Designer ElOther
-
Plan Check ID#SR Program/Element
49)46REV 10A)6 Rev 100406
CITY OF CUPERTINO
cqcq C-)� i
SWIMMING POOL/SPA
OF
CUPERTINO PERMIT APPI-41CATION FORM
APN # �2 Date:
Building Address:
� o2to N. �rr.,,- t
Mailing Address (if different from building address):
Owner's Name: Phone #:
�"d �r�So�, ._L��►�� C V irk► c� (03-03 Z`{ G'( O2 i
Contractor: (�, Phone#: Contractor License #:
`R. L 93&- 3 C Gl Z
FaK #: 4P � �)g5 ? � c�'3
Contact:,i Ie?4.,kzt rv%o e ►evtt ,s Prone#: 83(,39c,a__ Cupertino Business License #:
F,x #: Z o
Residential Commercial
Job Description: S Q ( , -M,,. �,2o-a; � — C�,v,� N c .tet >�, ,I—
( V6• 6 )
Valuation (cost of project): Square Footage:
RheXn— LG too v
Project Size: Express LJ Standard Large 0 Major
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set& the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1POOLCOMM Commercial Pool B CBSP
1BCBSC Cal Bldg Standards B ALL PERMIT
Commissio a Fee TYPES _
1BSEISMICO Seismic Commercial B
1POOLVINYL Vinyl-lined (up to B RBSP
800 sf)
1POOLFIBER Fiberglass B
CITY OF CUPERTINO
s4W SWIMMING POOL/SPA
CUPEI,TiNO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group Permit Type
I POOLGUNITE Gunite (up to 800 sf) B
1 SPAPREFAB Spa or Hot TO (Pre- B
fabricated)
1 SAUNA Steam Sauna B
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICR Seismic Resid.-ntial B
1PLMBLNCK Plumbing Plan Check P
1PPERMITFEE Plumbing Pennit P
1MPERMITFEE Mechanical Permit M
IEPERMITFEE Electric Permit E
1TRAVDOC Travel & Doc,imentation
1 BUSLIC Business Lice Ise B
n f ^/ Revised 01/07/09