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14010097 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1123 ELMSFORD DR CONTRACTOR:A-1 POOL REMOVEAL PERMIT NO:14010097 OWNER'S NAME: CAMPBELL,CA 95009 PHONE NO:(408)978-2903 LICENSED CONTRACTOWSeD``ECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE] License Class C /2 Lie.# 6�,7. SFDWL POOL REMOVAL 420 SQ FT Contractor r(/. j�Date I hereby affirm that I am licensed u der 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 self4fisure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the p�plbtmance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$6000 ave 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:36208011.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I 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 F OM S 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 by: Date: with all RE-ROOFS: Signature Date i/ti 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 inspection. ❑ O ER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,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, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the perforthance of the work for which this Owner or authorizedragent, ) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, .costs,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 non-point source regulations perthe Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date SWIMMING POOL / SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION G� 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•building(ftupertino.org �( CUPERTINO PROJECT ADDRESS /, I / APN# OWNER NAMEPHONE E-MAIL STREET ADDRESS �/ !—O� /L CITY, STAT VIP FAX CONTACT NAME /— PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OwNEERR-•BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER'/❑TENANT CONTRACTOR NA! /�L� /I/� `� �� LICEiVSENU�dBE �� LICENSETl(P2 BUS.L)sv _;,nig5 COMPANY AME f F• /�[r'` E-MAIL r FAX ✓, //'' o&I STREET ADDRESS CITY,STATE,ZIP PHONE �o V40 9 7 92 a 3 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK l'O O v/ r / USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S) STRUCTURE: ❑ Commercial POOL POOL/SPA MATERIAL TYPE CODES: SPA V - VINYL-LINED F - FIBERGLASS - DEMO s - GUNITE P - PREFABRICATED TOTAL VALUATION: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act o the pro owner's behalf I have read this VV application and the information I have provided is correct. I have read the Description of Work and verify it' ac e. I agree to comply with all applicable local ordinances and Date: (� L S PPLEME AL INF ON REQUIRED p - a . T _Commercial or Multi-Family Buildings with Public Swimming Pools: a Department of Environmental Health approval required. SwimPoolApp_201 Ldoc revised 03/16/11 CITY OF CUPERTINO D FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 1,123 elmsford dr DATE: 01/16/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$6,000 *PERMIT TYPE: Demolition Permit PLAN CIIE(7K T)'PE: PRIMARY PENTAMATION Swimming Pool, Res. 1SFP00LDEM USE: PERMIT TYPE: WORK sfdwl pool removal 420 sq ft SCOPE. FEE ID, #POOLS 1DEMOPRES 1 z x fi e _- ON < n ..._agg Meek Plan Check Plumb. Alun Check Elec-Plan c..-heck PeriaitTee: Plumb.Permit Fee: Elec. Permit Fee: Other Mech.Insp. Other Plumb Insp. Other Elec.Insp. 4ech.Insp.Fee. Plumb. lisp.Tee: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Thesefees are based on the preffim7dina information available and are only an estimate. Contact the Dept for addn7 info, FEE ITEMS (Fee Resolution 11-053 E . 71IIQ FEE QTY/FEE MISC ITEMS Plan Check 17 ee: Suppl. PCTee Plurnh.i�l lech./Elee Permit Fee: $319.00 Suppl. Insp.Fee-.0 Reg. ®OT 0,0 hrs $0.00 Plumb. Mech.A l,Ie; Plumh./Mech.%Elec Permit F'ee•. Conswitction Tax: Administrative Fee: Work:Without.Permit? Advanced Planning fees: Travel Documentation Fess: � Strong Motion Fee: IBSEISAfICR $0.60 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 $320.60 $0.00 6.1 $320.60 Revised: 01/15/2014 1,3 ' ptf© P4FR -rY L-s n/ E _ _ _ - - _ — _ - ---1 iv FX d- 5,'1 j /►NOTE j 5 0 nil ATN Y=� IV B w ro 13 E C t4?/0 A-6AN0aW ED /.1- 8A opt/ 13f/r L P Zl� ' 3 '' 1,021,2 s c AAS I f «I _ L 1 I pklvE -,,j?F-RTlN0 en Yom; UFF1 E COP�` "pi�flPLIANC 5 { P, � T G T /V6-r To sc4 COMPACTION REPORT IS REQUIRED SHOULD THE ABATED AREA BE DECLARED "BUILDABLE" IN THE FUTURE.