13010138CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22432 BALUSTROL CT
CONTRACTOR: PHILLIP D. BJURMAN
PERMIT NO: 13010138
OWNER'S NAME: DALE & EARL COLLINGS
1250 HIGHWY 101
DATE ISSUED: 01/28/2013
OWNER'S PHONE: 4088618806
AROMAS, CA 95004
PHONE NO: (650) 906.7533
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
c. # d 7� 2- J
License Class Lin
SFDWL POOL DEMO 400 SQ FT
r` �
^ Z 13
Contracto/> Date
I 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 certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $5000
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 35603017.00
Occupancy Type: -
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
- APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WIT 80 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 D OM LAST CALLED INSPECTION.
indemnify and keep hamless the City, of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: Date:.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
9.18:.
_
Signature L� f Da[e � !3
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
-
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one 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 structure is not intended or offered for sale (Sec.7044,
Business &-Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under 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 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 maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534. r
(31r
Section 3700 of the Labor Code, for the performance of the work for which this
Section
Owner or authorized agent-. a
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
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
APPLICANT CERTIFICATION
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
ARCHITECT'S DECLARATION
indemnify anit. keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accme 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 Date
Revised: 10/01/2012
PLOT PLANS
15
5 Ipool
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Resp ince- or,
to
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CUPERTINO
SWIMMING -POOL /SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255IS P
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(408) 777-3228 - FAX (408) 777-3333 • buildinalG�cuoertino.orG \^ b
PROJECT ADDRESS � �( 1 U ' ^�' /i -
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11OWNER ElOwNER.BUILDER 11OWHL�ERAGENf CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGMEER ❑ DEVELOPER ❑ TENANT
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ARCFUTEGTIENGINEER NAME
LICENSE NUMBER
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COMPANY NAME
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STREET ADDRESS
CITY, SPATE, ZIP
PHONE
DESCRIPTION OF ryORK
O1
USE OF ❑ SFD or Duplex ❑ Multi -Family
TYPE MATERIAL TYPE (CODE)
AREA (SQ. Fr.)
VALUATION (S)
STRUCTURE: ❑ Commercial
POOL
POOL/SPA MATERIAL TYPE CODES:
SPA
V - VINYL -LIKED
F - FIBERGLASS
DEMO
ll
G - GUNITE
P - PREFABRICATED
7.V
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TOTAL VALUATION:
is _ mw.¢S..an.-
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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 correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatingto buil ' o truction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicanNAgent Date:
SUPPLEMENTAL INFORMATION REQUIRED
us2.".00R” 0010
B�1C8E�IX .YP
OCUT iT _ _
_ Commercial or Multi -Family Buildings with Public Swimming Pools:_'
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Department of Environmental Health approval required.
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Swim PooUpp_2011.doc revised 03/16111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
10
ADDRESS: 22432 Balustrol Ct
DATE: 01/28/2013
REVIEWED BY: RDW
hlech. Permit Fee:
pPN:
BP#:
`VALUATION:
$5,000
*PERMIT TYPE: Demolition Permit
PLAN CHECK TYPE:
PRIMARY
USE: Swimming Pool, Res.
PE NTAMATION
PERMIT TYPE: 1SFP00LDEM
WORKPool
Demo
SCOPE
0,0
i i'+c,{
FEE ID
# POOLS
Plumb. Plan Check Elee. Plan Check
hlech. Permit Fee:
Plhmb. Permit Fee: Flee. Permit Pee:
Other A1ech. Insp
Other Plumb Insp. Other Elec. Insp. Li
1DEMOPRES
1
Phanh./Mech:/Elec
Permit Fee:
$306.00
Suppl. Insp. Fee -.0 Reg. Q OT
0,0
tns
$0.00
Plum h. /AAec^l h. /f lee
Plumb./Meeh./Elec Permit Fee:
Construction Tar:
Administrative Fee:
Work Without Permit?
Advanced Planning Fees:
A
Travel Do'ctunentation Fees:
Strong Motion Fee: IBSEISMICR
i i'+c,{
Much. Plan Check
Plumb. Plan Check Elee. Plan Check
hlech. Permit Fee:
Plhmb. Permit Fee: Flee. Permit Pee:
Other A1ech. Insp
Other Plumb Insp. Other Elec. Insp. Li
'.A9ech. Insp. Fee:
Plumb. hhsp. Fee: Elcc. Insp. Fee:
NOTE: This estimate does not ineludefees due to other Departments (de Planning, Public Works, Fire, Sanitary Sewer District, School
District eta These foes are based on the prellmin in ormation available and are only an estimate Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/U121
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
SuppL PC Fee
Phanh./Mech:/Elec
Permit Fee:
$306.00
Suppl. Insp. Fee -.0 Reg. Q OT
0,0
tns
$0.00
Plum h. /AAec^l h. /f lee
Plumb./Meeh./Elec Permit Fee:
Construction Tar:
Administrative Fee:
Work Without Permit?
Advanced Planning Fees:
A
Travel Do'ctunentation Fees:
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
1
Bldg Stds Commission Fee: 1BCBSC
$1.001
t
$307.50
$0.00µm TO1lAL4E
$307.50
Revised: 10/01/2012