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12120043CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10265 BEARDON DR OWNER'S NAME: WONG TONY AND DIANA TRUSTEE OWNER'S PHONE: 6509178188 ❑ . LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor 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. I 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 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 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 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 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 regulations per the Cupertino Municipal Code, Section 9.18. Signature Date ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I 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 Labor 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, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this 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 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 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 regulations per the Cupertino Municipal Code, Section 9.18. 1 %� Signature y Date l ' �/ I v CONTRACTOR: WONG TONY AND DIANA I PERMIT NO: 12120043 TRUSTEE 1 Z "J�1- 5e I' `(�0, 1- DATE ISSUED: 12/10/2012 Lp 2 & ( l b .� I O k - I Lf o �-Z— PHONE NO: BUILDING PERMIT INFO: BLDG f— ELECT PLUMB r- MECH RESIDENTIAL r— COMMERCIAL JOB DESCRIPTION: SWIMMING POOL DEMOLITION Sq. Ft Floor Area: I Valuation: $4000 APN Number: 32630041.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 D YS FROM_LAST CALLED INSPECTION. Issued by: Date: %2- 0- Z 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 agree to remove all new materials for inspection. Signature of Applicant: 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. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or author' I agent: 2 ' D� Date CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional X CUPIIRTINQ SWIMMING POOL / SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildinaancuperdno.org SP PROJECT ADDRESS / O - / `� F n I� APN 2— t ' OWNER NAME ( +Dk D Xp!(t �( —J �j I / `/ I D� I (J E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E -MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER OWNER- BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC N COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK , OL` S11 F—Xl S 7-Zti (7 / c' O L USE OF ❑ SFD or Duplex ❑ Multi - Family STRUCTURE: ❑ Commercial TYPE MATERIAL TYPE (CODE) AREA (SQ. FT.) VALUATION (S) POOL POOUSPA MATERIAL TYPE CODES: V - VINYL -LINED F - FIBERGLASS G - GUNTrB. P - PREFABRICATED SPA DEMO AEEE & ,a Y " TOTAL VALUATION 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 relating to building construction. I authorize representatives of Cupertino to enter the above - identified property3for inspection purposes. Signature of Applicant/Agent: Date: 2 0/" Z SUPPLEMENT T QUIRED _ Commercial or Multi - Family Buildings with Public Swimming Pools: Department of Environmental Health approval required. �. uQ__ � sPtIBEFR`OIZ(17E&T�- 'n��. � ;Is�IQI�•�� -��„„_ �� �.,.�_�7'����VERI?I &77ZIC� SwimPooUpp_2011.doc revised 03116111 CITY OF CUPERTINO D 191 FEE ESTIMATOR - BUILDING DIVISION FEE ID # POOLS 1 DEMOPRES --T ADDRESS: 10265 Beardon DR. DATE: 12/10/2012 REVIEWED BY: jsg rLIcch Pclk,ii7 1 ! "i". -L- APN: BP #: "VALUATION: 1$4,000 *PERMIT TYPE: Demolition Permit lPAN CHECK TI PRIMARY Swimming Pool, Res. PltfTn�7,i :!j It C'll.:'11E'C PENTAMATION 1 SFPOOLDEM USE: Permit Fee: PERMIT TYPE: WORK 0,0 hrs $0.00 SCOPE FEE ID # POOLS 1 DEMOPRES --T NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District eta These ees are based on the prelimina in formation available and are on1v an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff. 7/11122 Qc,h, Plan C'h((k QTY/FEE MISC ITEMS rLIcch Pclk,ii7 1 ! "i". -L- L-i olh t'1.!<7t -. En,v). Ll PltfTn�7,i :!j It C'll.:'11E'C NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District eta These ees are based on the prelimina in formation available and are on1v an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff. 7/11122 FEE QTY/FEE MISC ITEMS Plan Check Fee: ;5't ppl. PC.` FCC, PltfTn�7,i :!j It C'll.:'11E'C Permit Fee: $306.00 Suppl. Insp. Fee,0 Reg. Q OT 0,0 hrs $0.00 7'111nrEa. %1lecIr.:7:Tlcxc Permit FCC. t:Yott.lti ticti017 l ff. ,1rhninistr4xt1 vc Fee. j "F ork 11''ithodlC Pt :f'tifit? 11(AI(VItCCC1 Phir nin4; Fces Travel 0txsnne nfolion Fces,, Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $307.501 $0.00 TOTAL FEE: $307.50 Revised: 10/01/2012 I f 2 / a COPY ICE.