10110144 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10409 PINEVILLE AVE CONTRACTOR:KEVIN&JANE LEE PERMIT NO: 10110144
OWNER'S NAME: KEVIN&JANE LEE 10409 PINEVILLE AVE DATE ISSUED: 11/22/2010
ER'S PHONE: 3109387369 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r RESIDENTIAL F COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: SWIMMING POOL DEMO(I600SQ)
(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:$5000
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. APN Number:36913016.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by" / _ Date./ 2�1�
9.18.
Signature Date
RE-ROOFS:
y OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
0 installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 contracto to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code). v
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
emit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
p Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
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. CONSTRUCTION LENDING AGENCY
I hereby arm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION affirm
for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above info ation is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
i; iify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
cL. ,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date �"y Q
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36913016 .00
DATE ISSUED. . . . . . . : 11/22/2010
RECEIPT #. . . . . . . . . : BS000012067
REFERENCE ID # . . . : 10110144
SITE ADDRESS 10409 PINEVILLE AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER KEVIN & JANE LEE
ADDRESS 10409 PINEVILLE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JANE LEE
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : KEVIN & JANE LEE
ADDRESS 10409 PINEVILLE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 000 . 00 1. 00 0 . 00 1.00 0 .00
1BSEISMICR VALUATION 5, 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
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 292 .50 VISA
---------------
TOTAL RECEIPT 292 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
DEMOLITION
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10409 pineville ave. DATE: 11/22/2010 REVIEWED BY: bobs.
APN: BP#: *VALUATION: 1$3,500
*PERMIT TYPE: Demolition Permit ' - `(Jil (W /)'Pi
PRIMARY Swimming Pool, Res. PENTAMATION 1SFP00LDEM
USE: PERMIT TYPE:
WORK pool demo
SCOPE
FEE ID #POOLS
1DEMOPRES 1
NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS(Fee Resolution 09-051 El T'1,10) FEE QTY/FEE MISC ITEMS
t'la,l C he(:A Fec:
Sill)Ifd. P('0'et
Permit Fee: $291.00
Suppl. Insp. Feer Reg. 0 OT 0.0 hrs $0.00
f'larlrlh.-17�;'l,./I:tcc t/lir l e ':
1'lurllh.i:l7t t'17.;'I:lc't' 1't'vmif I'"c
( otlso-11crion Tax
ff'orh 11"ithout/'crolit'
1�117t11177itr 1'�ec:'; :
71-omel 0ocrimcntatiort
Strong Motion Fee: $0.00 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
1 1
SUBTOTALS: $292.00 $0.00 TOTAL FEE: $292.00
Revised: 11/08/2010
SWIMMING POOL REMOVAL REQUIREMENTS
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408)777-3333•buildingna,cupertino.orq
PURPOSE
The purpose of this guideline is to clarify the minimum requirements to allow for the removal of an
existing swimming pool. A demolition permit is required for the removal of all swimming pools.
PLAN REQUIREMENTS
1. Provide a completed demolition permit application.
2. Provide three sets on minimum 8-1/2"x 11" sheets of a completely dimensioned site plan showing
all property lines, all existing structures, location of existing swimming pool and setback
dimensions from the pool to the existing structures and property lines.
3. Owner-Builder Disclosure Form(for property owners applying for their own building permit)
GENERAL INFORMATION—IF THE POOL SHELL IS TO REMAIN
• Drill a minimum of three (3) - 12" diameter holes evenly spaced along the center line of the pool
bottom.
• Backfill the remaining pool shell with 3/4"maximum size crushed rock for a minimum of 8" deep
at the bottom of the pool. Gravel shall be packed into place. Clean fill may be added beyond the
initial crushed rock backfill.
• Backfill shall be moistened and tractor rolled or tamped with a wacker compacting plate into place.
• Two inspections are required. The initial inspection is to verify the required drain holes at the
bottom of the pool. The last and final inspection should be scheduled after all the work is
complete.
• No fill dirt shall be stored on the street or public right-of-way without an encroachment permit
issued by the Department of Public Works.
• Owner agrees the backfill over the existing swimming pool shell may have differential settlement
and agree to use the area for landscape purposes only and not use the area for any structural or
floor slab support until the pool shell is removed in its entirety an backfill is certified with
90% compaction.
FEE ESTIMATE FOR DEMOLITION OF SWIMMING POOL-The calculated fees-6 'Only an
estimate. Contact the Bldg Dept for additional info. -
*SCOPE OF WORK: Replacement Pe e $0.00
*VALUATION: $p Strong Motion Fee $0.00
Bldg Stds Commission Fee $0.00
*#OF SWIMMING POOLS: o TOTAL $0.00
SwimmingPoolRemoval.doc revised 11/16/10
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333- buildino(aDcuoertino.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 D �In� I Ile
�Ve
APN gP#
OWNERNAME -r n ,/I /Ae OWNER ADDRESS D�D� P-h e vl e �/
DESCRIPTION OF WORK: L/V ( l O m OI /V
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.)
4ilde
Iunderstand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
r 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.
At2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
e construction 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.nuI understand Contractors are required by law to be licensed and bonded in California and to list their license
mbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total 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
federaI 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.
r7. I understand under California Contractors'State License Law, an Owner-Builder who builds single-family esidential 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
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. 1 understand I may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service,the United States Small Business Administration,the Calofornia 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.csib.ca.gov for more information about licensed
contractors.
L10. I 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.
�— '
1-1 agree that,as the party legally and financially responsible for this construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
nformation I 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 complaints 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
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:
i
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 si natur
Property Owner's Signature: Date: << fl
- - - - --- --- - ---- -------------------------------------------------------------- -----------------------------------------------------
(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: Tel No
Address of Authorized Agent:
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.
Property Owner's Signature: Date:
OwnerBuilderForm_2010.doe revised 04/14/10
CITY OF CUPERTINO
DEMO
CUPEf�TINO PERMIT APPLICATION FORM
APN# �� C �� ' L) � �% Date: 1\ Z�- C)
Building Address: 0 ne V i � t � V�
l
Mailing Address (if different from building address):
Owner's Name: Phone:
VIh �a, Lem
Contractor: G L-0-0 vV4eX0,,_ Phone
R� "t Q-Va, �a v\JSC"'- t Fax:
Contractor License #: 61 t 9 Z
Cupertino Business License#:
Contact: f 1 Le Phone: -_3(o
Fax: I b
Residential Sq Footage b 0 0 Commercial ❑ Sq Footage
Job Description:
Lk) PO
Valuation:
Project Size: Express Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green 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 Demo Residential B 1SFP00L-DEM_
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 01/07/09