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09080008 CITY OF CUPERTIN O BUILDING PERMIT BUILDING ADDRESS: 11800 UPLAND WAY -ONTRACTOR:WILLIAM A HURT PERMIT NO:09080008 OWNER'S NAME: BENJAMIN LEE '.131 AMERST ST. DATE ISSUED:08/03/2009 ER'S PHONE: 4082187021 PALO ALTO,CA 94306 PHONE NO:(650)255-1802 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL Contractor Date JOB DESCRIPTION:POOL DEMOLITTON,2500 SQ 1 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 Sq.Ft Floor Area: Valuation:$20000 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 APN Number:36603016.01 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 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 180 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 DAYS FROM LAST CALLED INSPECTION. 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 Issued bDate: with all non-point source regulations per the Cupertino Municipal Code,Section R--7 9.18. 7J` Signature Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is OWNER-BUILDER DECLARATION installed without first obtaining an inspection,1 agree to remove all new materials for inspection. 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: 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, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three 1 have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air 1 have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall Ow ior authoriz agent: not employ any person in any manner so as to become subject to the Worker's Date:—Slt t3j�Gz7`) 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 CONSTRUCTION LENDING AGENCI' forthwith comply with such provisions or this permit shall be deemed revoked. 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.) APPLICANT CERTIFICATION Lender's Name I certify that 1 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 Lender's Address 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 i. iify and keep harmless the City of Cupertino against liabilities,judgments, cc, -and expenses which may accrue 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 nLl "_-It�� urce ons per the Cupertino Municipal Code,Section Licensed Professional 9.18. SignatureDate (J �0j"60oh CITY OF C-UPERTINO DIJMO CUPE�T1NO PERMIT APPLICATION FORM APN# Date: Building Address: 11100 Uf tq1,16 Mailing Address (if different from building addross): Owner's Name: Phone: 13E1*,).;ttr,1 K./ i_6(5 IVY - D- 19 -7"2l Contractor: Phone : - 5 w 1 YG z i rlUP_ Fax: Contractor License #: Cupertino Business License#: 3 S Contact: Phone: Fax: Residential Sq Footage :z Sc)cl Commercial ❑ Sq Footage Job Description: poet Erqd Valuation: Ccz Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Please complete relevant portions of the Gre(n Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residential B 1SFDWL-DEM 1DEMOPRES Pool Deino Residential B 1SFP00L-DEMV 1BCBSC Cal Bld;); Standards B ALL PERMIT Commission Fee TYPES I 1BSEISMICRE Seismic Residential B Revised 01/07/09 Community Development *, 10300 Torre Avenue `; Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ,UPEkTINO Building Department JOB ADDRESS: 000 L-,F1,nrrj,0 `Nl"K PERMIT# OWNER'S NAME: PHONE # #-pg -,l g 70A) GENERAL CONTRACTOR: FAX # I am not using any subcontractors: C),�fh-3IXW 9 Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI14ESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock /Tile Owner/Contractor Signature Date