15060200 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23025 VOSS AVE CONTRACTOR:POOL IT OUT PERMIT NO: 15060200
OWNER'S NAME: LUNA ROBERTO L AND JOSEFINA S 6443 S FRONT RD DATE ISSUED:06/30/2015
OWNER'S PHONE: 6509965340 LIVERMORE,CA 94550 PHONE NO:(877)665-6887
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
DEMO EXISTING POOL AND BACKFILL(FOR
License Class C Lic.# _ LANDSCAPE
PURPOSES ONLY)
Contractor I Date
I hereby affirm tha a licensed un er 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
ipe rmance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$9800
ve and will maintain Worker's Compensation Insurance,as provided for by
ion 3700 of the Labor Code,for the performance of the work for which this
P
it is issued. APN Number:34250015 00 OccupancN TNpe:
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 FROM LAST CALLED INSPEC IO .
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ? i
-
costs,and expenses which ay accrue against said City in consequence of theIssuedb �O 1.�1 v�"�� v Date: 6) I
granting of this permit. A ditinally the applicant understands and will comply y:
with all non-point so c egulatio r the Cupertino Municipal Code,Section
9.18. �--
ell ( 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
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)
1,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 it Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupe 'n Mun' 'pal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25 5, 5533, n 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Datero
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 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 per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
SWIMMING POOL / SPA PERMIT APPLICATION
r COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408) 777-3228• FAX (408)777-3333• building(d)cupertino.orcl i,5/°� O�
CUPERTINO 1 LAO
PROJECT ADDRESS V O C , r 77N# oQ 0 I�.
J \Jl
OWNER NAME n
L U n^ PHO � E-MAIL
STREET ADDRESS Z Q '/Q �lJ� CITY, STATE,ZIP v 1-1% rZ
FAX
l�tCONTACT NAME�aJ 1 �� PHOT Q E-MAIL
77 `� a - V -t
STREET ADDRESS G�_ u .M* CITY,STATE, ZIP L
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT01_t! TRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT, ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME J C r� �!' E
1W NUMBF48� /�f LICENSE TYPE BUS.LIC#
COMP1�E „o E-MAIL FAX
, �v
STREET ADDRESS /' C `,, f� LCITY,STATE,ZIP U vin ,/� PIIO tZI qYq-3)11
ARCHITECT/ENGINEER NAME J(J(/�r r` LICENSE NUMBER r BUS.LIC# /`
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK C
AL
O"I
USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION (S)
STRUCTURE: ❑ Commercial POOL
POOUSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO
1
G - GUNITE
P - PREFABRICATED RECEIVED BY TOTAL VALUATION:
T&� 0/ (�L C...I
By my signature below,I certify to eachof the oll wing: I m the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provide is o cve read the Description of Work and verify it is accurate. I a ree to co ply with all applicable local
ordinances and state laws relating to building n. authorize representatives of Cupertino to enter the above-�itlop rtyfo�spection purposes.
Signature of Applicant/Agent: Date: \v _
SUPPLEMENTAL rMFoRMATION REQUIRED OFFICE USE ONLY
PLAN CHECK TYPL ROUTING SLIP
Commercial or Multi-Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required. oN�R-rIlE-coUNrER ❑ BUILDINGDEPT
❑ EXPRESS ❑ PLANNING DEPT
❑ STANDARD ❑ PUBLTC WORKS DEPT
❑ LARGE ❑ I:NVIRONNIENTAL I]FALTH
❑ MAJOR ❑ SANITARY SEWER DISTRICT
SwimPooUpp_MLdoc revised 03/16/11
CITY OF CUPERTINO Cbmoo D
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 23025 VOSS AVE DATE: 06/30/2015 REVIEWED BY: PAUL
APN: 342 50 015 BP#: "VALUATION: 1$9,800
P.PERMITTYPE: Demolition Permit PLf1;1CIIh,C'liARY Swimming Pool, Res. PENTAMATION 1 SFPOOLDEM
USE: PERMIT TYPE:
WORK Demo existing pool and backfill FOR LANDSCAPE PURPOSES ONLY
SCOPE
FEE ID #POOLS
1DEMOPRES 1
Xlech. Plan 1'hrnrh. Ilan Cheed 1'.lec.Plan Check
alech. Pernr� FiWtlb. Permit Felaec 1'
Other llech. Insp Other Plumb Insp. Oiher Llec.Insp.
Wech.Insp. Fee: Plumb. hzsh. Fe" t_7ec. Insp. Fee:
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 Dept-for addn'l info.
FEE ITEMS(Fee Resolution 11-053 Eff Z11,1131 FEE QTY/FEE MISC ITEMS
suppl. "r'
"'l umh.%il fech.;Elec
Permit Fee: $329.00
Suppl. Insp. Fee-0 Reg. Q OT 0.0 hrs $0.00
°latrrtb.i111ec1r.;�1�`lcc
fltmh.ilLlech.'Flec Permit Fee:
�?tilruct
ltni;
'rtrk Withortt_Pernzil?
1vonced Planning P cc.s.
rUVel Documentation Fees:
Strong Motion Fee: IBSEISMICR $1.27 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $331.27 $0.00 TOTAL FEE: $331.27
Revised: 05/07/2015
S (Allynm ynoL ro
OFFIC COPY
dem a) YI
CO nCre - -
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CQ n C Ic ' COMMUNITY DEVELOPMENT DEP(kRTMENT
BUILDING DIVISION - CUPE TINO
APPROVED
This set of plans and specifications MUST e kept at the job site during construction. It is unlawful o make any
aAc� `( changes or alterations on same, or to deviate
�`��/ without approval from the Buil Jing Official.
o
G' L v �ing of this plan and specifications SHALL NOT
be held to permit or to be an approval of the violation
of any sions !f any City Ordinance r State Law.
BY
DATE
PERMIT # _
---- —
CUPERTI
Building Depa en )q^tgfL
JUN 3 0 201
SPS v4 E'Tf—�—
REVIEWED FOR CODE COMPLIANCE
Reviewed By:
h
Co