15010031I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21867 SHATTUCK DR I CONTRACTOR: ATHK CONSTRUCTION I PERMIT NO: 15010031
OWNER'S NAME:
1 SARATOGA, CA 95070 1 PHONE NO: (408) 849-2251
C LICENSED CONTRACTOR'S DECLARATION
License Class_ Lic. # `-/ 4_1 I
Contractor n -T -H i Date l .1
I hereby affirm that I am licensed under the provisions J 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.
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.
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
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,
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
9 18.
Signature A' Date � 5
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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.
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
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.
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
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,
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
9 18.
Signature Date
JOB DESCRIPTION: RESIDENTIAL [] COMMERCIAL ❑
SWIMMING POOL DEMO 600 SQ FT FOR FUTURE
ADDITION
90% COMPACTION
Sq. Ft Floor Area: I Valuation: $3000
APN Number: 35614003.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 PERMIT ISSUANCE OR
180 DAYS FOM ST CALLED INSPECTION.
Issued by: Date:
RE -ROOFS:
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.
Signature of Applicant: Date
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: l� Date: t 'S
CONSTRUCTION LENDING AGENCY
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 )
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
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TL'TT 1WQ9rTM A 9rni2 — RTTTT .TANG YHVISION
n
LaADDRESS: 21867 shattuck
—1— ------ - -- ------------
FEE
DATE: 01/07/2015
REVIEWED BY: Mendez
APN:
BP#:
"VALUATION: $3,000
*PERMIT TYPE: Demolition Permit
F71
PRIMARY Swimmin PoolRes.
9 ,
PENTAMATION 1 SFPOOLDEM
PERMIT TYPE:
USE:
Permit Fee:
$329.00
Suppl. Insp. Fee: Reg. ® OT
Q,Q
hrs
WORKswimmin
pool demo 600 s ft
z�
Per n -iii Fee:
SCOPE
P'e rm;f Fee.
;plat -h. Irzs�z /"ert:
Plumb. pal'i r Cheer
Plumb. Permit 1`ee
Other Plumb Inso
Plumb, hvq). Fee:
3�
t',Jec'..: ndtR-°t�PCrC
I is c.:rash, Fee:
NOTE: This estimate does not includelees due to otner mepartments (t.e. riunn,ng, X-"Ut9L rr v, nJ, L 91 G' ---y
_r_ .7..A1,.
—i ,,.,, „L.t„ n„ OIt;LHL/t0 ('n„tnrt thv Dint fnr addn'l info.
"139f L9, LLI.. . lIL— — -1/ u-- v...r.. ...r......•�.-•
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
—1— ------ - -- ------------
FEE
-
QTY/FEE
MISC ITEMS
111un Check Fee:
sappl, P(" Pee
F71
Permit Fee:
$329.00
Suppl. Insp. Fee: Reg. ® OT
Q,Q
hrs
$0.00
z�
Per n -iii Fee:
H'nrk kf"ilhou1 "'l-rrilif?
:'Iclt`(rFlt.e'L /11ttrnling FtTS:
Travelrt�rt<��I�xtI.ON Fees:
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
111111 wil"i;'11
$330.50
$0.00 r TOTAL FEE:
s
$330.50
Revised: 01/06/2015