12110003 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 20368 CLAY ST CONIR\CfOR:T09- '"LBE PF,RMITNO: 12110003
OWNER'S NAME: GROZMAN LENA A- I . Vim. DATE ISSUED: 11/01/2012
OWNER'S PIIONF,: 4084460945 PHONENO:
❑ LICENSED CONTRACT'OR'S DECLARATION
JOB IIESCRIP'fION: RFSI DFNTIA . COMMERCIAL[]
License Class �Z Lic.q G l8 6 Seo POOL DEMO 455 SQ FT
Contractor/ 2tM1wR / Date/ZI/
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 Illy lirense is in full force and effect.
hereby affirm under penally of perjury one of the fallmving two 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. Sq.FI 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
,UiN Number:36938028.00 Occupancy'[')PC:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state unit the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.1 agree to comply with all city and county ordinances aid 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 for inspection purposes. (We)agree to save 180 DAY FROM LAST CALLED INSPE TION.
indemnify and keep harmless the Cil'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 undcrstmnds and will comply Issued by: VI Date. � 2
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RF:ROOFS:
Signal e_ Date ff [ /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-lUILDFR DECLARATION
Signature of Applicant: Date:
hereby affirm that I am exempt from the Contractor's License Lae'far rune of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the stmcture is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IIALARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California lle:dth&Safety Code.Sections'-5505,25533,and 25534. 1 will
I hereby affirm under penalty of perjuqone of the follua'ing'three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ileahh&Safety Code.Section 25532(x)should I store or handle hazardous
1 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 Quality Management District
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and
I have and will maimain Worker's Compensation Insurance,as provided for by the I lealth&Safely Code,Sections 25505,255 3.and 25534.
Section 3700 of the Labor Code,for the performance of the work for Which this
Owner or authorized agpw-_-_12� Dmr.� Z �Z
permit is issued:
1 certify that in the performance of the work for which this permit is issued,1 shall
not employ any person in any manner so as to become subject to the Worker's
Compensation Imus ofCalifnnia. If,alter making this certificate 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. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
AI'I'I,ICAN'I'CISR'1'11+ICA"PION 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 cit'to enter
upon the above mentioned property for inspection purposes.(\1'e)agree to save ,\RCIII'1'FCI'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Dale
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SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION v
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 S\��O
(408)777-3228 • FAX(408)777-3333•building0cuoertino.oro \�
CUPERTINO
PROJECT ADDRESS o 3 49 C L GT APN 3to G '3'3s' Ci 2
OWNER NAhIF. =_ Z, •/ PHONE7� _Q I IYhINh
IVA
STREF?ADDRESS CITY•STATH.ZIP FAR
zo 6 C.4<J c� rP
CONTACT NAME / / 'J PIKA 7 0J E-MAII.
STRF.ETADDRESS J /� / CI ST ZIP FAX
O OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT O CONTRACTOR /CONTRACTOR AGENT ❑ ARCHRECT ❑ENGINEER ❑ DEN-ELOPER ❑TENANT
CONTRACTOR NAME 1ACE E 'UMGF„It LICE E S
M ' MPE NUS.LIC tl
XCOPANY E G-hIA1L(, A FAX ^J
STREFTADDRItSS Qv QO, /� /'7 CITY,SAr\'TG TI � r /� 9�p0 II(NQ
ARCIIrITC(ENGINEER NAME r L LICENSE NUMBER ` / BUS.LIC M / o
COMPANY NAh1E L-MAII. FAX
STREET ADDRESS CITY,STATE,ZIP PIIONE
DESCRIPTION OF WORK
6G — 15 r5l'S L14 /N
USE OF ❑ SFD or Duplex ❑ Multi-Family 'F)TH h1ATERIALTYPC(CODE) AREA (SQ,FT.) VALUATION (S)
STRUCTURE' ❑ Commercial POOL
POOLJSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO'
G - GUNITE
P - PREFABRICATED RECEIVED BY: 'I DIAL VALUATION:
OOb '� k
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 comet. I ave read the Description of Work and verify it is accurate. I agree to comply With all applicable local
ordinances and state laws rel Pon +uconstructs th resematives ofCupenino to enter the ubovveidentified property for inspection purposes.
Signature ol'ApplicanUA nt: Date:_( / Z / ir--
SUPPLI':htr Al. -ORMATI NREQUIltm) oFFlcF:useunl.v,
11Id,N CHECK I'1'14: N(IU'1'INCSLII' ') '
_Commercial or Multi-Family Buildings With Public Swimming fools:
Department of Environmental Health approval required. OVER-1'111+C'UUN'I'ER ❑, nUu.DINC DEPT -
❑ EXPRESS ❑ 14.ANXINC.Derr
❑ STANDARD - ' ❑ Puul.ICwoRKS'Derr -
❑' L\RCE ❑ f:S\'IR(1\']IEN"1'.U:IIEw L'TIh
❑ NIAJOR ❑ SANII%,R\'SEW'E'R DISI'RIC]
'.
S,i nPoo1App_201 Ldoc revised 03//611/
CiTY OF CUPERTINO D
FE IMATOR - BUILDING DIVISION
ADDRESS: 20363 clay/ct DATE: 11/01/2012 REVIEWED BY: mendez
APN: BP#: 'VALUATION: $7,000
*PERMITTYPE: Demolition Permit PLAN CHECK TYPE:
PRIMARY PENTAMATION
USE: Swimming Pool, Res. PERMITTYPE: 1SFP00LDEM
At
WORK POOL DEMO OF 455 SQ FT
SCOPE
FEEID # POOLS
• 1DEMOPRES 1
Mech.Plan Check Phunb. Plum Check Elec. Ilan Check
blecb.Permit Fee: Plumb.Permit Fec: lilec•.Permit Fee:
Other d&ch./asp. Other Plumb Insp. Other Elce.hap.
.Mech.Insp. Fee: Plumb. hup.Fee: Elec.Lap.Fac:
NOTE: This eviintate doev not includejees due to other Departments(i.e. Planning, Public Warks, Fire,Sanitary Sewer District,School
District, etc. . These fecy are based on lite prelintinart•information mailable and are only an estimate. Contact lite Dept for addit7 in o.
FEE ITEMS (Fee Resohuion 11-053 Elf 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fec::
Suppl. PC Fec
Plumb./MechAlec
Permit Fee: $306.00
Suppl. Insp. Fee:Q Reg. Q OT F0,0 hrs $0.00
Plumb.4fech./Elee
Plumb.4lech./F.lee Permit Fee:
Consnntction Tax:
Administrative Fee:
fk'ork IVidtout Permit?
Advanced Planting Fees:
Travel Documentation Fees: I A
Strong Motion Fee: IBSEISMICR $0.70 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $307.701 $0.001 TOTAL FEE: $307.70
Revised: 10/01/2012