14080021 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19773 WINTERGREEN DR CONTRACTOR:FOUR SEASONS PERMIT NO: 14080021
GARDENING
OWNER'S NAME: LI ZHEN AND LIU LIMIN 2429 LAST OAK DR DATE ISSUED:08/05/2014
OWNER'S PHONE: 4084261131 SAN JOSE,CA 95124 PHONE NO:(408)426-1131
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
/ REMOVAL OF SFDWL POOL 384 SQ FT
License Class if_Z� Li,.# ,/��'7 1(f�
Contractor Kt-CJ Date �i-
I hereby affirm that I am licensed under t e 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
ompensation,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:$6900
1 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:36909028.00 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 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 DAY M LAST CALLED INSP7TION.
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 non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signatu —Date —''�y 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
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,
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 25 ,2553 and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized age Date:
permit is issued.
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
SWIMMING POOL 1 SPA PERMIT APPLICATIO lY
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION6
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408)777-3333•buildingacupertino.org
1
PROJECT ADDRESS 3 G� APN# f n 6
OWNERNAM s PH E E-MAIL
�LK
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME�G j n_ LICENZN"RJ LICEN E TYPE BUS.LIC#
COMPANY NAME •J jf(� E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
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 SC L
POOL/SPA MATERIAL TYPE CODES: SPA (J
V - VINYL-LINED
F - FIBERGLASS - DEMO
GUNITE
PREFABRICATEDCEIYE Y TOTAL V L b
gnaw
By my signature below,I certify to each of the following: I am the propertywn or authorized 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 Des_ ion of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil ing construe. n. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Appl icant/Agent Date:
SUPPLEMENTAL INF ATION REQUIRED �xOFFICE usEONLY
,7� 4 CI�CK.TXPEv= ROUTING SLIP
_Commercial or Multi-Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required. ovr CourtmER .'°� ❑ BUILDING DEPT
n � i .s
EXPRESS ❑ PLANNING DEPT
STANDARD. ❑ PUBLIC WORKS DEPT
❑h ARGE. ❑ ENVIRONMENTAL HEALTH
, VVI'A-J12R. �„9�.; ❑ SANTTARY-SEWERDISTRICT -:.
SwimPoolApp_201 1.doc revised 03/16/11
CITY OF CUPERTINO D
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19773 wintergreen dr DATE: 08/05/2014 REVIEWED BY: Mendez
APN: BP#: -VALUATION: $6,900
PERMIT TYPE: DemolltlOn Permit Yt,-�N C 11hC`K I�Yt'L
PRIMARY PENTAMATION
USE: Swimming Pool, Res. PERMIT TYPE: 1SFP00LDE
WORK removal of sfdwl pool 384 sq ft
SCOPE
FEE ID #POOLS
1DEMOPRES
i",.`cr P!iwlb. Plan Chcei,
el_ 1'>rrnit f`ee� Plumb,
0
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77 tt f 1�ec'i. lr"'v' 0117er/'/omit 7nspa 0111?`r t iaa fpn�p
l�zc ?. Iristf_ t°�< hixrFaZ�. Ti¢R'�1. F'e: Lit, I�t,> 1°>c-
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Ef: 7i} 1/13) FEE QTY/FEE MISC ITEMS
Permit Fee: $329.00
Suppl. Insp. Fee:Q Reg. Q OT 1 0,0 hrs $0.00
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32,
b� r
PERTI O
l S' �.Jilding Department
UG 0 2014
REVIEWED FOR CODE COMPLIAN E
19773 VQ; v%+eyCl,..on,,, •t�v, Reviewed By:
F F '�
COMMUNITY DE�JELOPMENT DEPARTMENT
BUILDING DIVISION-CUPERTINO
F S?
Thi--Getof plans and specifics ons MUST be kept at the
drurbq construction. is unlawful to make any
`: :♦ �;or Sita;utions o same,or to deviate
�r,Eti�out approval •om the Building Official. S/7 Fr
I
�' ifiG^dors SALL NOT �'C� -
c;%d, nnot G
ajjCe o J: ,'e Law.