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12070099 CiTY OF CUPERTiNO BUILDING PERMIT BUILDING ADDRESS: 20925 PEPPER TRCC LN CONTRAC`T'OR:BLUE RAY PERMIT NO: 12070099 REMODELING CO O\VNER'S NANO: THOMAS NG&ZIIILING ZIIANG 1200 RANCHERO WAY DATE ISSUED:07/132012 OWNER'S PRONE: 4156096988 SAN JOSE,CA 95117 PHONE NO:(408)615-0135 ❑ LICENSED CO\fRAC*fOR'S DECLARATION .TOB DESCRIPTION: RF,SIDEN 1AL COpI\IFKCI,\I, License Class Lic.9 PARTIAL POOL DEMO REDUCE HEIGHT APPROX 12" Contractor Date hereby amen that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that nrr license is in fall force and effect. hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insurc 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 Sq.Ft Floor Area: Valuation:$6500 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 APN Number.35912014.00 Occupancy'1'ypc permit is issued. ,\rrl.lcA�r cr:R'nr•lccnoN I certify that l have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. l agree to comply with all city mid county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property 1'or inspection purposes. (We)agree to save 180 9AYS FROI�'�.LAST CALLED INSPECTION. indenmifv and keep harmless the City of Cupertino against liabilities,judgments, S costs,mid expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued Dy:t4v Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. BE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed Ira roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ,r}y15 OWNER-BUILDER DECLARATION v (- Signature of Applicant: Date: I hereby affirm thin 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO HE CLASS"A"OR RE ITER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,:tad the structure is not intended or offered for sale(See.7044, Business&Professions Code) L,as owner of the property,am exclusively contracting with licensed contractors to IIAZARDOIIS BL\TERIAI S DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&SafetyCode,Sections 25505,25533,and 25534. 1 will hereby affirm trader penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the declarations: Health&Safety Code.Section 25532(a)should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Ray Area AirgualityManagement District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino �ripal Code.Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safeq'Code.Sections 25505 '5633,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this 3 Owner or authorized agent: Date:�� permit is issued. - I certify that in the performance of die work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to die Worker's Compensation laws of California. If,after making this ccnificate of exemption,I CONSTRIICI'ION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked w'ork's for which this permit is issued(Sec.3097,Cie C.) Leader's Name \PI'LIG\N'I'Cbatl'IF'IC,\'PION Leader's Address 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 to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to sae indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCIIITECI"S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Adt itionalfy'�ie applicant understands and will comply with all non-point source regGiations,per the Cupertino Municipal Code,Section Licensed Professional 9.18. SignatureDate /'L CITY OF CUPERTINO D FEE ESTIMATOR - BUILDING DIVISION 7ADDRESS: 20925 pepper tree In DATE: REVIEWED BY: larry s \ RP#: 'VALUATION: $6,500 *PERMITTI'PE: Demolition Permit PL,IN CHECK TYPE: PRIMARY Swimming Pool, Res. PERMIMAT10iV 1SFP00LDEM USE: PER1fITTl'PE: WORK ool artial demolition SCOPE FEE ID # POOLS 1DEMOPRES 1 Meeh, flan Check Plumb. Plan Check Elea Plan Check Mech.Permit Fee: Plumb.Permit Fee: Elec,Permit Fee: Other,l/erh. Insp. Other Plumb Insp. Other Fier./nap. Ej ilech.htep.Fee: Plumb. blip.Fee: Elec./lisp.Fee: NOTE: This estimate does not include jeev due to other Departments(i.e. Planting, Public Works. Fire,SanitarySewer District,Schaal District,etc.). There feav are hosed on the prelintinan•information available and lire only an estimate Contact the Dept for adrht7 in a. FEE ITEMS (Fee Resolution 11-0531-8 7111112 FEE QTY/FEE MISC ITEMS Plan Check Fec: Srrppl. PC Fee Phtmb.1A4ech.1E1ec Permit Fee: $306.00 SuppI. Insp. FeeQ Reg. Q OT 0.0 L hrs $0.00 Phonb.1jl%ch.1E1ee Phtmh./A•lech./Elec Permit Fee: Construction Tac: Administrative Fee: Mork Without Permil? Advanced Planting Fees: Travel Documentation Fees: Stionk Motion Fee: IBSFlSh/ICR $0.65 Select an Administrative Item 131c1a Suds Commission Fec: IBCBSC $1.00 SU13TOTALS: $307.651 $0.001 TOTAL FEE:. $307.65 Revised: 07/01/2012 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 • building(acuoenino.orG CUPERTINO A, 67e9©�q PROJECT ADDRESS I APNA � —4— /2 O /p� y OWNER NAME O PHONE D /4we E-MAILnlj.M- STREET ADDRESS v) CITY,STATE ZIP / 7�� FAX `'�/`i \•W"", CONTACT NAME ) / PHONE E-MAIL STREET ADDRESS ^ ^ CTTY.STATE. ZIP FAX OWNER ❑ OWNER-BUILDER ❑ OWNERAGENi ❑ CONTRACTOR ❑CON RAC ORAGENr ❑ ARCH!MCT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Nu L �( /\. CEISE NUMBER /� / LICENSE TYPE BUS.LIC A COMPANY NAME � W Y\j n(,() LIE-MALL o FAX STREET ADDRESS �i I CRY,STATE ZIP PHONE / V ARCHTTECTlENGINEER:VA.ME LICENSE NUMBER BUS.LIC A Uh J CO.WANY NAME E-MAIL FAX STREET ADDRESS I CITY,STATE,ZIP PHONE DESCAJPTION OF WORK USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S) S RUCrUµE: ❑ Commercial FOOL A POOLISPA MATERLIL TYPE CODES: SPA V - VrNYL-LINED F - FIBERGLASS DEMO G - Gi1NRE P - PREFABRICATED `§REEELVEDHY '�' � +.•t TOTAL VALUATION: ' I•.5•-.xxt' �<eF� e's-fi.�si r•G�-'c ate.s-�.� 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 provided is come ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building co z'1,autho�rize�represenmdvcs of Cupertino:o enter the above.idpn'£ed pmpe�for mspecaon purposes. Signature of ApplimrntAgenC ''/ /v` ( Date: ``66////C I LL 201-Z- SUPPLEMENTAL SUPPLEMENTAL INFORMATION RE UIRE Q ,s.�eaPffi\��.Y•,eCH�C�'RYPE��_��'_„1.`,�� '- R t7�T1-YG9�1P.-T �l Commercial orMulti-Family Buildings with Public Swimming Pools - „—x' ., -�. 1 COUNTS at� t,,, ;�s-•+ '�'.� Department of Envirotunental Health approval required ILEM�,M 0 ,,,L7'aBrtMB�cn ,.,. _ RPf -'�*.' x. - -�-.4x`�S"'•'}��-?-i'`.t"� �s"-ra`aT�+,awl '^ `�.-�SF�AY➢�A±R�D���4 aP3�'\EVBCI w�OpR�pEWI- �y �,�GRG �`����.s1 QeL�r.����L_"+`"'�.\e�iaC•g`T# ri(�..\L\J 0.•w=r'"" `'x-"'--` X33`y"=+"ifANiTARL`S£wERDIs1R---- SwimPooUpp_201 Ldoc revised 03/16/11 OWNER-BUILDER DISCLOSURE FORM • COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333• buildinc(c),cuoertino.orc 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'26oJ , APN -OI BP# OWNER NAMEOWNER ADDRESS D C 26 L E r DESCRIPTION OF WORK: 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.) I 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. 1, 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. I understand building permits are not required to be signed by property owners unless they are responsible for the c6struction and are not hiring a licensed Contractor to assume this responsibility. 4Kf 3. I 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. .l'Akli(t understand Contractors are required by law to be licensed and bonded in California and to list their license numybe�rs on permits and contracts. a. 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. "l 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. 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. 6° finaInLicial nderstand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OienerBuilderh-orm 20I0.doo revised04114/10 T_ t,d`9. I 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 contcontractors.�a l4 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I a_m the party legally and financially responsible for proposed construction activity at the site address listed above. ''G 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all a plicable laws and requirements that govern Owner-Builders as well as employers. I 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 you may 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 permjtrNote:A copy of the property owner's driver's license, form notarization, or other verification acceptable to theci y may be required to be presented when the permit is issued to verify the property owners signature. Property Owner's Signature: Date: 3 y ----- -- ---- -- — ----------- ------- --------------------------- ---- -------------...----------------- - (NOTE: The following-Autho- -ri--zation- Form is required to be completed by the property owner only when designating an----- agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF 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: Tel No Address of Authorized Agent: 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 owners drivers 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 owners signature. Property Owners Signature: Date: 0wnerBuilderForm 1010.doc revised 04114110 Plan Review Process Worl<F (V wed By:Pa - vis /03 SWIMMING POOL REMOVAL REQUIREMENTS COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408)777-3333 • buildinq(a).cugertino.orq PURPOSE The purpose of this guideline is to clarify the minimum requirements to allow for the removal of an existing swimming pool. A construction permit is required for the removal of all swimming pools. PLAN REQUIRENIENTS 1. Provide a completed swimming pool (SP) permit application. 2. Provide three sets on minimum 8-1/2" x 11" sheets of a completely dimensioned site plan showing all property lines, all existing structures, location of existing swimming pool and setback dimensions from the pool to the existing structures and property lines. 3. Owner-Builder Disclosure Fonn (for property owners applying for their own building permit) GENERAL INFOIZNIATION—IF THE POOL SHELL IS TO REbIAL 1 • Drill a minimum of three (3) - 12" diameter holes evenly spaced along the center line of the pool bottom. • Backfill the remaining pool shell with 'W' maximum size crushed rock for a minimum of 8" deep at the bottom of the pool. Gravel shall be packed into place. Clean 611 may be added beyond the initial crushed rock backfill. • Backfill shall be moistened and tractor rolled or tamped with a wacker compacting plate into place. • Two inspections are required. The initial inspection is to verify the required drain holes at the bottom of the pool. The last and final inspection should be scheduled after all the work is complete. IVF-D I No fill dirt shall be stored on the street or public right-of-way without an encroachment,permit issued by the Department of Public Works. JUL. t J cu it • Owner agrees the backfill over the existing swimming pool shell may have ddiff irential settlement ' and agree to use the area for landscape purposes duly and not use the area for any structural or floor slab support until the pool shell is removed in its entirety and theyl ackfill is certified with 90% compaction. FEE ESTIMATE FOR DEMOLITION OF SWIMMING POOL: Theeldul5ursftij "o,dVt� off estimate. Contact the Bldg Dept for additional in o. CUPERTINO j *USE OF BUILDING: Resident Building DepartrPenitit Fee $0.00 *VALUATION: �p . Strong Motion Fee $0.00 JUL 133M� tds Commission Fee $0.00 *# OF SWIMNtrNG POOLS: o # TOTAL REVIEWED F R CODE PLIANCE $0.00 -Reviewed By: SoimmingPoolRemoval.dot revised 06/21/11 4E 8' H Pool 16' 19' House �C�.IVE� • JUL 13 2012 BY:OFFICL. 7ppq®-, Building Department l 20925 Pepper ree Ln, Cupertino, CAIN JUL 13 2012 REVIEWED FFR CODE vCIANCE Reviewed By: