11050139 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1673 GALWAY DR CONTRACTOR; 'ERMIT NO: 11050139
OWNER'S NAME: KEENLY RICHARD R AND CYNTHIA A UZA vwc— ATE ISSUED:05/17/2011
OWNER'S PHONE: 4082064573 PHONE NO:
L. LICENSED CONTRACTOR'S DECLARATION
/ (� p� BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class C %50 Lic.# 6,3 7�J O
/ MECH RESIDENTIAL COMMERCIAL
94Contractor - /t S�ee� Date l
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:DEMO RESIDENTIAL SWIMMING POOL(400SQFT)
(commencing with Section 7000)of Division 3 of the Business&Professions SEE NOTES
Code and that my license is in full force and effect.
V lq .
I hereby affirm under penalty of perjury one of the following two declarations:
[Ifie 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 Sq.Ft Floor Area: Valuation:$3000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36624028.00 , Occupancy Type:
APPLICANT CERTIFICATION
1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of thiTPA. Additionally,the applicant understands and will comply
with all non-pource r ulations per the C�upeo Municipal Code,Section
9.18. Issued by: Date:
Signat r Date � �7111
r OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain mpliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health afety)C?de,Sectigns 25505,25533,and 25534.
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 ate:
forthwith comply with such provisions or this permit shall be deemed revoked. /
C, _ CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of cork's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
coy*e,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
ig of this permit.Additionally,the applicant understands and will comply
V dll non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36624028 . 00
DATE ISSUED. . . . . . . : 05/17/2011
RECEIPT #. . . . . . . . . : BS000013475
REFERENCE ID # . . . : 11050139.
SITE ADDRESS . . . . . : 1673 GALWAY DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER KEENLY RICHARD R AND CYNTHIA A
ADDRESS 1673 GALWAY DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5240
RECEIVED FROM . . . . : JOSE ALCANTAR
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 3, 000 .00 1. 00 0. 00 1. 00 0.00
1BSEISMICR VALUATION 3, 000. 00 0 .50 0 . 00 0 .50 0. 00
1DEMOPRE EACH 1 .00 291. 00 0. 00 291. 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 292 .50 0 . 00 292 .50 0. 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
11105 0/31_
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
2 (408)777-3228• FAX(408)777-3333•building(&cupertino.org
CUPERTINO
PROJECT ADDRESS %�. 73 Ca L w a40A APN# �)
OWNER NAMEC�a �je e"L PHONE �j0 Q 57 E-MAIL
STREET ADDRESS /v 73 L VU a � CITY, STATE,t v ea 45 P FAX
CONTACT NAME if PHONE 7 E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME TO S� ICQ� � LICENSE NUMBER z �) J LICENSE TYPE BUS.LIC#
COMPANY NAME /lv1 la 7 � �.� E-MAIL S I7,e1_C-os`� (e Poles c�►sl , FAX
STREET ADDRESS CrI-Y,STATE, pa V Y PHONrZ�e r � ttf�
7
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
eGuaCrlte
USE OF ErIFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S)
STRUCTURE: ❑ Commercial POOL
POOUSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO Gj' oo S. _ 3 O00
G - GUNITE
P - PREFABRICATED RECEIVED BY; - TOTAL VALUATION.
By my signature below,I certify to e h 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 h provided is correct. have read Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating building tructio I authori re tatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicandAgent.. Date: �f'
SUPPLE TAL INFORMATION REQUIRED O.MCE USZ ONLY
PLAN CHECK TYPE �'ROUTINGSLIP .`
_Commercial or Multi-Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required. OVER-TH&COUNTER fes"BUILDING DEPT
'EXPRESS D^.PLANNING DEPT
STANDARD ❑,.PUBLIC WORKS DEPT
❑'LARGE _ M",ENVIRONMENTAL;HEALTH;
❑`MAJOR D' SANITARY SEWER DISTRICT
SwimPoolApp_201 Ldoc revised 03/16/11
DEMOLITION
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
MDDRESS: 1673 galway dr. DATE: 05/17/2011 REVIEWED BY: bobs.
PN: BP#: EVALUATION: 1$3,000
°PERMIT TYPE: Demolition Permit
PRIMARY Swimming Pool, Res. PENTAMATION 1SFPOOLDEM
USE: PERMIT TYPE:
WORK demo residential swimming pool.
SCOPE
FEE ID #POOLS
1 DEMOPRES 'I
F-1 q---1 Li 0 L
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (Cee Resolution 09-051 f;jf'.' 7;'1.-10) FEE QTY/FEE MISC ITEMS
Permit Fee: $291.00
Suppl.Insp.Fee.e Reg. 00T F0.0 hrs $0.00
A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: 1 $292.501 $0.00 TOTAL FEE: $292.50
Revised: 04/29/2011
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