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11100136 CITY OF CUPERTINC BUILDING PERMIT BUILDING ADDRESS: 21820 GARDENVIEW LN CONTRACTOR:BOB'S BOBCAT PERMIT NO: 11100136 SERVICE,INC. OWNER'S NAME: SHTEYN YEVGENIY EUGENE 567 ARLETA AVE DATE ISSUED: 10/18/2011 )WNER'S PHONE: 4082424981 SAN JOSE,CA 95128 PHONE NO:(408)998-8766 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL License Class C%'(ok Lic.# d 4( r G SFDWL POOL DEMO 880 SQ FT Contractor �p-+ a e eW 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. Sq.Ft Floor Area: Valuation:$14000 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 APN Number:32619097.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION /f— 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 WITHIN IAO 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 LAST CALLED INSPECTIO indemnify and keep harmless the City of Cupertino against liabilities,judgments, . costs,and expenses which may accrue against said City in consequence of the Date: granting of this permit. Additionally,the applicant understands and will comply Issued by: with all non-point source regulations per the Cupertino Municipal Code,Section If 9.18. RE-ROOFS: Signature Date 16—t El( 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 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) I,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. 1 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 I 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 I performance of the work for which this permit is issued. will maintain compliance with the Cupertino M nicipa Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 25 ,and 534. xx Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent: Date: I certify that in the performance of the work for which this permit is issued,I shall not employ any person inany manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION 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 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 and keep harmless the City of Cupertino against liabilities,judgments, Is,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. ,nting 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 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: �2,( ,a,2Qc. PERMIT# OWNER'S NAME: PHONE# C-4af- `d of e-t'� G G GENERAL CONTRACTO W%vscv USINESS LICENSE # C C `� ADDRESS: rf (�,�P CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALLSUB O TRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. / I am not using any subcontractors: O Signature V Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor SVhature Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32619097. 00 DATE ISSUED. . . . . . . : 10/18/2011 RECEIPT #. . . . . . . . . : BS000015078 REFERENCE ID # . . . : 11100136 SITE ADDRESS . . . . . : 21820 GARDENVIEW LN SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : SHTEYN YEVGENIY EUGENE ADDRESS . . . . . . . . . . : 21820 GARDENVIEW LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : BOB'S BOBCAT CONTRACTOR . . . . . . . : ROBERT L ASHBY LIC # 30638 COMPANY . . . . . . . . . . : BOB'S BOBCAT SERVICE, INC. ADDRESS . . . . . . . . . . : 567 ARLETA AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95128 TELEPHONE . . . . . . . . : (408) 998-8766 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 14, 000 . 00 1. 00 0 . 00 1 .00 0 . 00 1BSEISMICR VALUATION 14, 000. 00 1.40 0 . 00 1 .40 0 . 00 1DEMOPRE EACH 1. 00 300. 00 0. 00 300 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 302 .40 0. 00 302 .40 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 302 .40 5919 --------------- TOTAL RECEIPT 302 .40 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO SWIMMING POOL I SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 S P tJPERYlNO (408)777-3228• FAX(408)777-3333 •buildingacupertino.org PROJECT ADDRESS T W en,v` , APN# 3-2 ( „ /�, '\ OWNER NAME / PHONE C (��/ E-MAIL v �'I STREET ADDRESS O STATE ZIP A. CONTACT NAME4 v' PHO EMAILt4L 4_�_ A o 1 STREET ADDRESS �� /�J w �} CrTY Ste,ZIP A A S/ FA �^ ❑OWNER ❑ OWNER-BUILDER `❑ OWNER AGENT /( CONTRACTOR ❑CONTRACTOR AGENT /�❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER /❑ TENANT CO J%kN `_ l�� LICENSE ��' LICEIrE T/P BUS.LIC# Je_ If COMPANY NAME E-MAIL (� FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S) STRUCTURE: ❑ Commercial POOL / POOLISPA MATERIAL TYPE CODES: SPA V - VINYL-LINED F - FIBERGLASS DEMO G - GUNTTE P - PREFABRICATED &� � � TOTAL VUATIONN:�y,,� CSV 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 ha provi d i rrect. 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 b ' ctio I thorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: `��^ 4 r SUPPLEMENTAL INFORMATION VQUIRED "� _Commercial or Multi-Family Buildings with Public Swimming Pools: Department of Environmental Health approval required. t � � ;:s • ��,.,��-� ,� -��-ter os Q> F Ir�10 F »iE1�ilT?FR7ESFWEI�I7IS�ItI :_.. ._ SwimPoolApp 2011.doc revised 03/16/11