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11040105I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10171 E ESTATES DR I CONTRACTOR: LP CONSTRUCTION CO I PERMIT NO: 11040105 OWNER'S NAME: FLESHMAN STEVEN G AND RITA K E WNER'S PHONE: 4082575766 ❑ 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. Date OWNER -BUILDER DECLARATION I((heereby 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). r 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, :ts, and expenses which may accrue against said City in consequence of the anting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. / Z i 360 E EVELYN AVE #440 DATE ISSUED: 04/15/2011 SUNNYVALE, CA 94086 PHONE NO: (408) 234-3731 JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL POOL DEMO Sq. Ft Floor Area: I Valuation: $6800 APN Number: 36908004.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 18 S OF PERMIT ISSUANCE OR 180 DAYS FR LAST CALLED INSPECTI N. Issued by: Date: 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 I 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 authorized agent:� 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 3 ITEMS OF 3 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36908004.00 DATE ISSUED.......: 04/15/2011 RECEIPT #......... BS000013200 REFERENCE ID # ...: 11040105 SITE ADDRESS .....: 10171 E ESTATES DR SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OPERATOR: SylviaM COPY # : 1 OWNER FLESHMAN STEVEN G AND RITA K E ADDRESS 10171 E ESTATES DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3303 RECEIVED FROM ....: LAURA SMITH CONTRACTOR LEO PICOLLO LIC # 29039 COMPANY LP CONSTRUCTION CO ADDRESS 360 E EVELYN AVE #440 CITY/STATE/ZIP ...: SUNNYVALE, CA 94086 TELEPHONE ........: (408) 234-3731 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL ---------- ----------------------- 1BCBSC VALUATION ---------- 6,800.00 ---------- 1.00 ---------- 0.00 1.00 0.00 1BSEISMICR VALUATION 6,800.00 0.68 0.00 0.68 0.00 1DEMOPRE EACH 1.00 291.00 0.00 291.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 292.68 ---------- 0.00 292.68 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 292.68 --------------- 292.68 REFERENCE NUMBER -------------------- 240 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO DEMOLITION CITY OF CUPERTINO WE FEE ESTIMATOR - BUILDING DIVISION FEE ID #POOLS 1DEMOPRES ivuj E: i nese fees are oasea on tne Pretinunary information avaitalple ana are only an estimate. Contact the Dept for addnl into. FEE ITEMS (1'ee Resolution 09-051 7-1,`10) FEE QTY/FEE MISC ITEMS A Permit Fee: $291.00 Suppl. Insp. Fee -0 Reg. 0 OT 0.0 hrs $0.00 Strong- Motion Fee: IBSEISMICR $0.68 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 1 SUBTOTALS: $292.681 $0.00r TOTAL FEE: $292.6 Revised: 01/15/2011 ADDRESS: 10171 e. estates dr. DATE: 04/15/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: 1$6,805 PERMIT TYPE: Demolition Permit PRIMARY Swimming Pool, USE: Res. -T PENTAMATION 1SFP00LDEM 1PERMIT TYPE: WORK demo residential gunite pool. SCOPE FEE ID #POOLS 1DEMOPRES ivuj E: i nese fees are oasea on tne Pretinunary information avaitalple ana are only an estimate. Contact the Dept for addnl into. FEE ITEMS (1'ee Resolution 09-051 7-1,`10) FEE QTY/FEE MISC ITEMS A Permit Fee: $291.00 Suppl. Insp. Fee -0 Reg. 0 OT 0.0 hrs $0.00 Strong- Motion Fee: IBSEISMICR $0.68 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 1 SUBTOTALS: $292.681 $0.00r TOTAL FEE: $292.6 Revised: 01/15/2011 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(d,)cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# OWNER NPME kt�' 4a j OWNER ADDRESS DESCRIPTION OF WORK: ? F' . We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Ilder' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for t onstruction and are not hiring a licensed Contractor to assume this responsibility. . I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license m ers on permits and contracts. -'5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the t tal value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. I understand if I am considered an "employer" under state and federal law, I must register with the state and fe eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for a y financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal ve enue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide b -all -applicable laws and requirements that govern Owner -Builders as well as employers. agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in rmation-1 have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: — - -------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. I Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 A I C0MMUNnYro VaDpMe 'r CVARTMWr BUILDING DIVISION - CUPERTINO ,APPROVED This set of plans and specificadons MUST be kept at the job site during construction- It is unlawful to make any changes or alterations same, B i�di�i�� therefrom, without app u' specifications SHALL NOT The stamping of this plan and spec �- be held to permit or to be an approval of the violation of any provisions ofan City Ordinance or State Law. BY . - DATE DFRMIT NO. f 741 i. GSR a i I g a �V J `tea J Z A I C0MMUNnYro VaDpMe 'r CVARTMWr BUILDING DIVISION - CUPERTINO ,APPROVED This set of plans and specificadons MUST be kept at the job site during construction- It is unlawful to make any changes or alterations same, B i�di�i�� therefrom, without app u' specifications SHALL NOT The stamping of this plan and spec �- be held to permit or to be an approval of the violation of any provisions ofan City Ordinance or State Law. BY . - DATE DFRMIT NO. f 741 i. GSR a i I g a �V CUPERTINO SWIMMING POOL / SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildincl aacupertino.orq 4 a 1164-010s PROJECT ADDRESS J- L '+ � Z � (� /� 4!_S. / J ,— I APN # '11,V Q4 U OWNER NAME PHO 7 �� E-MAIL 29t/i� t'-4 /' C STREET ADDRESSCITY, Csf�� STATE, ZIP FAX Z--, ff' r c �' +� a `2 CONTACT NAME ! 1= j PHO r r -y ! E-MAIL STREET ADDRESS CIT TATE, ZIP i 1 / C / FAX OWNER 11 OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME�� LICENSE NUMB LICENSE TYPE BUS. LIC # L e.ti COMPANY NAr E-MAIL FAX ST ET ADD S CIT ,STATE, ZIP PHONE ^ ARCHIITECT/ENGINEEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK ; I/ N 61 >� C G P 7! d�eil �J 'G P +YL USE OF R -51 7b or Duplex p Multi -Family TYPE MATERIAL TYPE (CODE) AREA (SQ. FT.) VALUATION ($) STRUCTURE: ❑ Commercial POOL POOL/SPA MATERIAL TYPE CODES: SPA V - VINYL -LINED F - FIBERGLASS DEMO%c-lr f r G - GUNITE C✓ RECEIVED BY: TOTAL ALUATION: If D U P - PREFABRICATED I 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 aut iae representatives of Cupertino to enter the above-ident led prope for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OM4 USE ONLY PLAN CHECK TYPE ROUTING SLIP _ Commercial or Multi -Family Buildings with Public Swimming Pools: C3"ovEiz-TxE couNTER CF'B n NG Department of Environmental Health approval required. DEPT ❑ EXPRESS ' ❑ PLANNING DEPT ❑ STANDARD ❑ PUBLIC WORKS DEPT ❑ LARGE ❑ ENVIRONMENTAL HEALTH ❑ MAJOR ❑ SANITARY SEWER DISTRICT SwimPoolApp_201 Ldoc revised 03/16/11