09080008 (2) 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