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12060043CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18761 PENDERGAST AVE I CONTRACTOR: MICFIAEL TROPIi LIANIN I PERMIT NO: 12060043 I OWNER'SNAME: MICIIAELTROPHLIANIN 1105 ASH CT IDATE ISSUED: 06/07/2012 I OWNER'S PHONE.: 6502196059 I LOS GATOS, CA 95032- I PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic.H Contractor Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a ccnificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance ollhe work fir which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code. lir the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I cenify 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 authorizx representatives of (his city to enter upon the above mentioned properly loot inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may acerae agains(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 9.18. ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Low for one of the following two reasons: L 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. Business & Professions Code) h as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044. Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 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 Section 3700 of the Lahor Code, for the performance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California If, alter making this certificate ofexemption, I become subject to the Workers Compensation provisions ofthe Labor Code, I must forthwith comply with such provisions or (his permit shall be deemed revoked. 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 stale laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for 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 granting of this permit Additionally, the applicant understands and will comply with all non -point source regulalitns c Cupertino Municipal Code, Section 9.18. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: DEMO OF SINGLE [:AMITY DWELLING SWIMMING POOL AT RFAR YARD LOCATION Sq. FI Floor Area: I Valuation: $8000 APN Number: 37527034 00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued e., h��Date-9,7 7 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed If a roof is installed without first obtaining an inspection. I agar to remme all neomaterials for inspection. Signature of Date ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health & Safety Cade, Section 25532(x) should 1 store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bov Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Seetions 505, 25533, and 25534. Ow ner or out n: _ Dale:__�4y!� CONSTRlKT10N LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Scc. 3097. Civ C.) Lender's Name Lender's ARCIII'TF.CT'S DECLARATION I understand my plans shall be used as public records. Licensed 3 ITEMS OF 3 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN 37527034.00 DATE ISSUED.......: 06/07/2012 RECEIPT #.........: BS000017020 REFERENCE ID # ...: 12060043 SITE ADDRESS .....: 18761 PENDERGAST AVE SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT AMOUNT ---------301.80 --------------- 301.80 REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION VOICE ID 'DESCRIPTION -- ---------------------------- ----------------- --------- 704 DEMO OWNER ............: MICHAEL TROPHLIANIN ADDRESS ..........: 105 ASH CT CITY/STATE/ZIP ...: LOS GATOS, CA 95032 - RECEIVED FROM ....: MICHAEL TROFLIANIN CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: MICHAEL TROPHLIANIN ADDRESS ..........: 105 ASH CT CITY/STATE/ZIP ...: LOS GATOS, CA 95032 - TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- ---------- 1BCBSC ----------------------- VALUATION 8,000.00 ---------- ---------- 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 8,000.00 0.80 0.00 0.80 0.00 1DEMOPRE EACH 1.00 300.00 0.00 300.00 0.00 TOTAL PERMIT 301.80 0.00 301.80 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT AMOUNT ---------301.80 --------------- 301.80 REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION VOICE ID 'DESCRIPTION -- ---------------------------- ----------------- --------- 704 DEMO CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 " FAX (408) 777-3333 - building5cuoertino.oro Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS /v / nen APN B12c>601960 o 6ao 60 OWNER N ME mg /-- tisk- OWNER ADDRESS DESCRIPTION OF WORK: /42,e kOOeze,_ We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) Pl— 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. C2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. k�T 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. (fLE-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. I:f'L5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer under state and federal law. #CE_6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. IfIT 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. PT 8.1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 01, nerBuilderForrn 2010. doe rei ised 04/14/10 RT 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. KT 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. X11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. 911-12. 1 agree to notify the issuer -of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss youimay sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and.wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city mayAgXaquired to be presented when the permit is issued Property Owner's Signature: Date: e� 7//2 -- - - --- -- -- ------ -- ------- - - -- -- -- ......--- -- -- -- -- --- —- -- ---- —Thefollowing Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply fora construction permit for the Owner -Builder). AUTHORIZATIONtOF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: M00 I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signatuie: Date: Oune/'BuilderFornl 2010.doc revised 04/14//0 51&!�iS•in 3S� " H's 1 - q r- 91.424- 1 b V S� JUN,.o 7 2012. S:6prSf t L M r�6' W CUPERTINO` - _� Bulldln Department 9' R. V ''`''� �`�' JUN 0 7 ' 912 ��."— • REVIEWED FOR COD COM LIQ E Reviewed By:d�- 4'�- Yc)Q .cc too 3�; �3 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION FEE ID H POOLS 1DEMOPRES 1 ADDRESS: 18761 penedergast DATE: 06/07/2012 R EVIEWED BY: bobs. t,nnif Per: APN: BPH: 'VALUATION: $8,000 *PERMIT TYPE: Demolition Permit 1'l.,d:vC1/li('IC717'h:: PRIMARY Swimming Pool, Res. USE: lilrr. Ir+sp. l',a': PENTAMATION 1SFP00LDEM PERMIT TYPE: WORK demo sfd swimming pool at rear yard location. SCOPE 0,0 FEE ID H POOLS 1DEMOPRES 1 NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the prellminary information available and are onb' an estimate Contact the Dept for addn7 info. FEE ITEMS (Fue Resolution 11-053 EB: 711111) l/rah. Phm ('h, r'n P/ ... nh. l4nu C'hr<'6 /:Ire. P/an (I,r, A t,nnif Per: P/.... b. linrri, ISr: likr. 11uvr,ir P� r. Ulhrr 1/rrh. /' ikhrr Humb b,e'p. iI/hrr' Flex. la,p_ .Idrah. bt,p. I- Phrnih. 1".y. Fr.: lilrr. Ir+sp. l',a': NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the prellminary information available and are onb' an estimate Contact the Dept for addn7 info. FEE ITEMS (Fue Resolution 11-053 EB: 711111) FEE QTY/FEE MISC ITEMS l'lun C hc, 1, 1.,r: Suppt VC I t•,: Pholdf irlL'i lt. 117, 1: Permit Fee: $300.00 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 P/wnh../lIc, h./P:feu l' lumh.i,ldr(lr./likr ll:rmil I�•c: Con,%ii It, tifm rl�hnini.vn',nilr 14 r: b;4,r/r II'ithnut Perm iii' ;Irknu ed /'lamming l res: IIf mcl l)nr'tunrnt(it inn hcc'.s. Strone Motion I ce: IBSEISMICR $0.80 Select an Administrative Item Bkhd Sids Commission Fee. IBCBSC $1.00 SUBTOTALS: 1 $301.80 $0.00 TOTAL FEE: 1 $301.80 Revised: 06/05/2012 CUPERTINO i 2,c) SWIMMING POOL / SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 S P (408) 777-3228 • FAX (408) 777-3333 • buildina(tilcuoertino.ora PROJECT ADDRESS 11:iplLe ( � / APN R'32� 'I^j L, 4] OWNER NAME PHONE6�0-2/pF.�MAIL (J STREET ADDRESS CI�/ / V ` C"Y. 1 O6MAll.�A_� FAX CONTACT NAME. PHOO'NEgm- sq ^ � �,1J JOV_IIg/ STREET ADDRESS Ia O CITY, S TE, ZIP CSF a sw A FA�Xq _61 ❑ OWNER ❑ OWNER -BUILDER 10 OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR N'ANF. LICENSENUMBER j LICENSE YPe BUS, LICA /-�O COMPANYNAME O Y J, — E—MA OSCC FAX STREET ADDRESS CITY,STATE,ZI PHON�Ei.V�Q�-J'(�� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC R COMPANY NAME. E-MAIL FAX STREET ADDRESS CITY. STATE, ZIP PI ZONE DESCRIPTION OF WORK o� SwLmml oar USE OF FD or Duplex ❑ Multi -Family STRUCTURE: ❑ Commercial TYPE MATERIAL TYPE (CODE) AREA (SQ. FT.) VALUATION (S) POOL/f (�-•hi�W'r� Szo L POOISPA MATERIAL TYPE CODES: V - VINYI: LINED F - FIBERGLASS 2GD GUNITF P - PREFABRICATED SPA DEMO RECEIVED BY: By my signature below, I certify to each of the following: application and the information I have provided is correct. ordinances and state laws relating to building constru Signature of ApplicanUAgen..Date: I am the property owner or authorized agent to act on the property owner's behalf. I have read this I have KcadAhe1Te§Cripti0n of Work and verify it is accurate. I agree to comply with all applicable local orize representatives of Cupertino to enter the above -identified property for inspection purposes. SUPPLEMENTAL I ` OR ON REQUIRED Commercial or Multi -Family Buildings with Public Swimming Pools: Department of Environmental Health approval required. OFFICE USE ONLY PLAN CHECK TYPE ROUTING SLIP -OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR' G DEPT ❑ PLANNING DEPT ❑ PUBLIC WORKS DEPT ❑ ENVIRONMENTALHEALTH ❑ SANITARY SEWER DISTRICT SvimPoolApp_2011.doc revised 03116111 M