14050131 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 858 LILY AVE CONTRACTOR:HAULING PROS PERMIT NO: 14050131
OWNER'S NAME: MARY JANE OLMSTEAD PO BOX 4033 DATE ISSUED:05/22/2014
OWNER'S PHONE: 4089963465 WALNUT CREEK,CA 94596 PHONE NO:(925)682-8987
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
p DEMO(E)505 S.F.POOL,FILL FOR LANDSCAPE
License Class Li..# (� , PURPOSES ONLY
Contractor �" /a S Date
I 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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5000
+iTave 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:35903038.00 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 D 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 Y 'L Z
granting of this permit. Additionally,the applicant understands and will comply I Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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 performance of the work for which this
permit is issued. Owner or authorized age . Date:
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
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 per the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
127 I
SWIMMING POOL / SPA PERMIT APPLICATION
O\
Is COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 /
CUPERTINO (408)777-3228•FAX(408)777-3333•building aacupertino.org
PROJECT ADDRESS �� APN# 35- Q _ o 3 03
k
OWNER NAME PHONE ry E-MAIL
STREET ADDRESSO L,/ CITY, STATE,ZIP FAX
ell
CONTACT NAME PHO E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER �❑ OWNER AGENT XONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER5eL/�f�/yaICSE r , BUS.LIC#
COMPANY NAME c� E-MAIL /(O C/ �T FAX
STREET ADDRESS CITY,STATE,ZIP PHON :�r 2
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION($)
STRUCTURE: ❑ Commercial POOL
POOIJSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO
G - GUNITE w
P - PREFABRICATED TOTAL VALUATION:,_
By my signature below,I certify to each of the following: I ArSe property o nzed agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bui g ction. I authorize representatives of Cupertino to enter the above-identi ed prope for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENM INFORMATION REQUIRED o
r
Commercial or Multi-Family Buildings with Public Swimming Pools: -
Department of Environmental Health approval required.
G O AL4YEALT
,Q_ d,ffiS �AAY3SEWER`DLS �C51? .
SwimPoolApp_2011.doc revised 03/16/11
CITY OF CUPERTINO D
1jjjFEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 858 LILY AVE DATE: 05/22/2014 REVIEWED BY: MELISSA
APN: 359 03 038 BP#: *VALUATION: $5,000
*PERMIT TYPE: Demolition Permit PIA N CH/lI 'K N"/>L
PRIMARY PENTAMATION
USE: Swimming Pool, Res. PERMIT TYPE: 1 SFPOOLDE
WORK DEMO E 505 S.F. POOL FILL FOR LANDSCAPE PURPOSES ONLY
SCOPE
FEE ID #POOLS
1DEMOPRES I
1�cir. PI rrt i rrac!{ P/will. Plan('hc'd;
l h-":h Pi'/"'mi"Fete: Purr!). Pc:r-mb T ire: A7"( Pcrr t t",E,.
(hlwr Plumb 7nsr1. E3
Oihel'k/61(. h7sp. Lj
5 racra lit fir.1'e°er Tl7srrttr. 111NI). I`i'i': l:k:e.It' t>o:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Theseees are based on the relimina information available and are onlyan estimate. Contact the Det or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7ff /1/13) FEE QTY/FEE MISC ITEMS
1'1trrn . ;14e It.il'lec
Permit Fee: $319.00
Suppl. Insp. Fee:(E) Reg. ® OT 0.0 hrs $0.00
Elec
1'lund) Per viii Fee:
.(JP ivffr„`�'E�tJf� 3 ir.`tom.
iF�r�t`li �'{'illir�ttl�'c'r`1�111>
/klC{rming Fees:
I1`t?i''Z 1)ftc°t irte'nf tllttr"d Fees. �
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
W4 M- S $320.50 $0.00 TOTAL FEE: $320.50
m`,�' 4
Revised: 04/01/2014
o-Er
� I
oilY 1
_ 1
I Gi CCl
CUPERTINO
1
t 5'a if ti41q V'.Mout ap,provai from tita i. uilI j Q7i{Cl2.l, '
1
Building Department '
1
c , T 1 ;
T�1.�i`z 'r`t 'itl o this p! '1 and � ¢ .iEiCati uE"'E<•.i.L(`-� I
y�
1_,� f("� .F' q.n �v Ulld{G'.iOn �..n ` I
� ,.,, ` ,. `tai Law. ✓1�l SC0. e
1
' POOL to be removed
REViEir
' �iEu rOFZ CODE COMPLIANCE ;
1
Reviewed By: Area= 504.20 sq ft
License#834$30,9254334448 PE' SIT NO. a ��IUSOZ � ;
109.00 Perimeter= 92.10 ft
----------------
r-I-OPBILY 1111U
0
- - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - -
Property
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Property line 6.60 '
' I
Walls line
I
y IO - - - - - - - - - - - I w w v w w �- - O
( I
W J W V W O
O
HOUSE
O '
o
co
— � �■ O
y ti w W y W W W W W W J+ �L t - - - - -
y y W y 'k y W � I w 4, y W t
v 1P w y + w y y w 1 I
w W W W W 41 J, W W W
W W W W •Y WY W y W y W �t^ t. Eaves Ine
Y W W
41
W W W W J ( O
41JF W J� y y I
w y W W W y W
----------------
PLOT PLANS
100.00
c
858 Lily Ave
}
ICE LANNING D�P'j' Cupertino,CA 95014
scale V:10'