12080146 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 8151 PRESIDIO DR CONTRACTOR:HAULING PROS PERMITNO: 12080146
OWNER'S NAME: DA ROZA EDWARD LAND ELSIE LT PO BOX 4033 DATE ISSUED:08/142012
OWNER'S PI IONP:: 4089008077 WALNUT CREEK,CA 94596 PIIONE NO:(925)682-8987
❑ LICENSED CONTRAC'TOR'S DECLARATION .1011 DESCRIPTION: RESIDE\PIAL COMMERCIAL[]
License Class .c.N RESIDENTIAL POOLDEP70
Contractor ate
1 hereby a1Tir at 1 am licensed un�=hcovisions of Chapter 9
(commenci ilh Section 7000)of Division 3 of the Business S Professions
Code an at my license is in full force orad effect.
1 herebyaffirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent to sell-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. Sq.Ft Floor Area: Valuation:$7000
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:35611086.00 Occupancy Type:
permit is Issued.
APPLICANT CIiRTIFICATION
I ccnify that I have read this application and state that the above infomnation is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 1 SO DAYS OF PERMIT ISSUANCE OR
to building construclion,.and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue ago.0 i id City in consequence of the ��77 p �/`�
granting of this pennil. A nall}' _ plicanl understands and will comply' Issued by: /,��/f L!-Tl�t� Date: l -l7 !-
with all non-point s e alai er the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Dam b / L All roofs shall be inspected prior to any roofing material being installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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 K Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to I IAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business 3 Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health S Safety Code.Sections 25505,25533,and 25534. I will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ileallh S Safely Code,Section 25532(x)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 Bay Area Air Q t* NI Agement District
performance of the work for which this permit is issued will maintain compliance with the Caper}' ode.Chapter 9.1'_and
I have mid will maintain Worker's Compensation Insurance,as provided for by the Ilealth S Safety Code,Sections�- .255. id 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Darr.
permit is issued l
I certify that in the performance of the work for which this permit is issued I shall
not employ any person in any mamer so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I ONS"PRI1C1-ION 117ND ING 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.)
Lender's Name
A1'P1,ICA\I'CER'1'IFICA"TION Lender'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 save
indemnify and keep harmless the Cin'of Cupertino against l iahilities,judgmems, ARCI IITEC`I"S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plain shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comps'
with all non-paint source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO D
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 8151 Presidio Dr. DATE: 08114/2012 REVIEWED BY: Sean
APN: BP#: WALUATION: 1$7,000
*PERMVPTYPE: Demolition Permit PLdNCHECKTYPE:
PRIMARY PENTANvaiON
USE: Swimming Pool, Res. PFRINHT I.YPF: 1SFP00LDE A
WORK Demolition of in-ground gunite swimming pool 596 sq ft).
SCOPE
FEE 11) #POOLS
1DEMOPRES 1
Meeh. Plan Check Plumb. Plan Check Flee.Plat Check
Mech. Permit Fee: Plumb.Permit Fee: Fee.Permit Fee:
Other Mech.lnsp. Other Plumb Insp. Other Elec.lase.
Mitch. bap.Fee: Plumb. Pup. Fre: Elec.Insp.Fee:
A'OTE: This eslinmte does not include fees due to other Departments(i.e. Planning. Public Works, Fire,Sanitag Server District,School
District. etc.). Thesefees are baser/on the trelintinan•in ortnation available and are only an ettinutle. Contact the Dept for ar/tln 7 info.
FEE ITEMS (Fee Resohuion 11-053 EtL 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
SuppL PC Fee
Plumb.hblech.Mec
Permit Fee: $306.00
Supp1. Insp. Fee.,G Reg. Q OT 0.0 1 hrs $0.00
Plumb.lMech./Elec
Plunih./Mech.Mec Pm-mit Fee:
Consn•uction Tax:
Administrative Fee:
Work Without Permit?
Adronced Planning Feer:
Travel Documentation Fees: A
Strom Motion Fee: IBSEISMICR $0.70 Select an Administrative Item
131dg Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $307.70 $0.00 TOTAL FEE: $307.70
Revised: 07/01/2012
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SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT' BUILDING DIVISION P10300 TORRE AVENUE t CUPERTINO. CA 95014-3255
CUPERTINO (408)777-3228 • FAX(408)777-3333 'buildinafGDcuoenino.orD
g �
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PROJECT ADDRESS II' I /D /✓ I APN A
WER /7•�•y
ONNAME b C G�M1,J, PHONE O O_ oO�✓/ I I E-%Am
STREET ADDRESS CITY. STA'IEZEP O I FAX
CONTACT NAA¢ a J •/r Gt I PHONE I E-MAR
STRIR ADDRESS CITY.STATE, ZIP FAX
❑ OWNER ❑ OWNER-HMDER ❑ O%T AGENT ❑ CONTRACTOR ❑CONIAAMR AGENT ❑ A cNrrECr ❑ENGINEER ❑ ovnoPER ❑T} ANT
CONTAACTOA NAME LICENSE
yG 3 I LI=E I HUS.LIC I 2u/�
COMPANY NAME J E-MAIL FAX
S7Ac_i ADDRESS I CITY,STATE,ZIP I PHONE
AACHRECTIENGINEEANAME LICENSE NUMBER BUS.LICI
COMPA.W NAME / C ECaW (/4!/W I FAX
SiTtT'7 ADDRESS 7,3 �• RUC /ct•n •� =11.STA
DESCRIPTION OF WORK
UU 1
USE OF .SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA
(SQ.Fr.) .VALUATION (s)
ST LUCTUKE: ❑ Commercial Pool
POOLISPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEM
G - GUNTM
P - PAEFABRIGID TasA-EQ.E..EV�m_ ' Yti""�"=ems"'-•- rt�--^ '- TOTALVALUA"ON:
By my signature below,I certify to each of the folIA-111f< property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provide co L . ve read the Description of Work and verify it is accurate. I agree_w comply with all applicable local
ordinances and sate laws relating to buil ' g c c' . I authorize repreeer adves of Cupertino-,a enter the above-idend d prope for"mupecdon purposes .
Signature Df ApplicanJAgenn Date: x l
SUPPLENrL IATION REQUMED
,se.:5�as.�w.OFEICE�U5E:0: ��
pRAN.CHEOCT.YPE: ;� - "ROGTLYG
Cornntercial or Muld-Family Buildi.•tgs with Public Swimming Pools: -a-•gra-rte
Department of Environmental Health
approval required. 47=R-'raB•cD TETe, au¢nLlcnEzt-
WPM
STAI'nAliD 5`• ���EDRLICtWORi(,S•i,DEPt
,-�sAtiTrxbu'sEWEtentsxud�.-�-
SwimPoolApp_011.doc revised 03/16/11