10080201 CITY OF CUPERTINO BUILDING PERMIT
WILDING ADDRESS: 20770 CHERYL DR CONTRACTOR:SAMUEL S TING&WINNIE PERMIT NO: 10080201
H TU
"'TIER'S NAME:
CUPERT[NO,CA 95014 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION F C"
BUILDIIIG PERMIT INFO: BLDG ELECT PLUMB
.icense Class Lic.# F
MECH RESIDENTIAL COMMERCIAL
:ontractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DE 3CRIPTION:POOL DEMOLITION-1570SQ
commencing with Section 7000)of Division 3 of the Business&Professions
lode and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
have and will maintain a certificate of consent to self-insure for Worker's
,ompensation,as provided for by Section 3700 of the Labor Code,for the
>erformance of the work for which this permit is issued. Sq.Ft Fla or Area: Valuation:$5500
have and will maintain Worker's Compensation Insurance,as provided for by
lection 3700 of the Labor Code,for the performance of the work for which this
>ermit is issued. APN Nuniber:35916015.00 Occupancy Type:
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
;orrect.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
o building construction,and hereby authorize representatives of this city to enter
ipon the above mentioned property for inspection purposes. (We)agree to save WI THIN 180 DAYS OF PERMIT ISSUANCE OR
ndemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
:osts,and expenses which may accrue against said City in consequence of the
;ranting of this permit. Additionally,the applicant understands and will comply
vvith all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date: e—2 7-0
I.18.
--nature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs:,hall be inspected prior to any roofing material being installed.If a roof is
installed N iithout 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:
[,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)
[,as owner of the property,am exclusively contracting with licensed co tors;to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
-onstnuct the project(Sec.7044,Business&Professions Code). �`,��/
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have retd 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 Addition illy,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 contamin ants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,l 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 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 rev ed. CO TRUCTION LENDING AGENCY
I hereby-,ffirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information 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
the above mentioned property for inspection purposes.(We)agree to save
unify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I underst nd 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
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISICDEMOLITION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: 'VALUATION: 1$5,500
*PERMIT TYPE: Demolition Permit
PRIMARY Swimming Pool, Res. PENTAMATION 1SFPOOLDEM
USE: PERMIT TYPE:
WORK
SCOPE
FEE ID #POOLS
1 DEMOPRES 'I
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j37R, ge k''r r $ !� %c� "� �t.%° 'x+'3 ��3p. P' �� �° "Et
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NOTE: Thesefees are based on the preliminary in ormation available a 7d are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS(Fee Resolution 09-051 Elf 7i1i10) FEE QTY/FEE MISC ITEMS
Plan Chec.A I-ec.
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Permit Fee: $291.00
Suppl. Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00
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/'lur�rf,.;'A1ec/r.i%>lc�c Pcrrruir F c.
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Strom, Motion Fee: $0.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
l's $292.00 $0.00 _ � F� � k' $292.00
Revised: 8/17/2010