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09090081 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 943 BROOKGROVE LN CONTRACTOR:BOB'S BOBCAT SERVICE, PERMIT NO:09090081 INC. OWNER'S NAME: BRESLAUER NORMAN S AND LOUELLA 567 ARLETA AVE DATE ISSUED:09/11/2009 ER'S PHONE: 4082530276 SAN JOSE,CA 95128 PHONE NO:(408)998-8766 LICENSED CONTRACTOR'S DECLARATION .'-- BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class T 2-1 Lie.# _ / MECH RESIDENTIAL COMMERCIAL Contractor s � Date ( l( —0,2- 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTIOMFIBERGLASS SWIMMING POOL DEMO&BACK- (commencing with Section 7000)of Division 3 of the Business&Professions FILL 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:$8300 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:37539029.00 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: -�/�0ri; 9,18. Signature Date RE-ROOFS: CJ OWNER-BUILDER DECLARATION 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 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) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct 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 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 maintain compliance • h the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Saf ty Code ections 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 t agent: Compensation laws of California, If,after making this certificate of exemption,I Date: r 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 affirm 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 mify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION 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 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY ## 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 37539029 . 00 DATE ISSUED. . . . . . . : 09/11/2009 RECEIPT #. . . . . . . . . BS000008658 REFERENCE ID .# . . . 09090081 SITE ADDRESS . . . . . : 943 BROOKGROVE LN SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER BRESLAUER NORMAN S AND LOUELLA ADDRESS 943 BROOKGROVE LN CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4667 RECEIVED FROM . . . . : BOB'S BOBCAT SERVIC CONTRACTOR . . . . . . . : ROBERT L ASHBY LIC # 30638 COMPANY BOB' S BOBCAT SERVICE, INC. ADDRESS 567 ARLETA AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95128 TELEPHONE (408) 998-8766 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 8, 300 . 00 1. 00 0. 00 1. 00 0 .00 1BSEISMICR VALUATION 8, 300. 00 0 . 90 0 . 00 0 . 90 0 .00 1DEMOPRE SQUARE FEET 0 . 00 490 . 00 0 . 00 490 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 491 .90 0 .00 491. 90 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 491 . 90 #5177 --------------- TOTAL RECEIPT 491 . 90 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO 09 C)q C)ua i CITY OF CUPERTINO at DEMO CUPEkTINO PERMIT APPLICATION FORM APN# Date: l IL-5 3 �� . a Building Address-: 4 nctk q ro ii LA ,)-e— Mailing Address (if differentkom building address): Owner's Name: Phone: L 0 1), � �L�__3 - Contractor: Phone : 4/G6 � dl , CC- � Fax: 416C' F0 '-764" Contractor License #: S_7-36e-(2- Cupertino 6L(2- Cu ertino Business License #: Contact: Phone: A �S Fax: Residential Sq Footage Commercial ❑ Sq Footage Job DescriptP6 Inc' io 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 i 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 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF -UPEf�TINO Fax(408)777-3333 Building Department JOB ADDRESS: PERMIT # J p. ,7q-1 �rec-Ae � w� 0� o OWNER'S NAME: vPHONE # GENERAL CONTRACTOR FAX# V9C- 42 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS 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 Ile,/�*-z J4 -� 1- Owner Contr �Cor Signature Date