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15100192CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10336 E ESTATES DR CONTRACTOR: GROH JUNE B TRUSTEE PERMIT NO: 15100192 & ET AL OWNER'S NAME: GROH JUNE B TRUSTEE & ET AL 10336 E ESTATES DR DATE ISSUED: 10/23/2015 OWNER'S PHONE: 4082522939 CUPERTINO, CA 95014-3305 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REMOVE (E) SWIMMING POOL & FILL FOR LANDSCAPE License Class Lic. # PURPOSES ONLY Contractor 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. Sq. Ft Floor Area: Valuation: $1000 I hereby affirm under penalty of perjury one of the following two declarations: 1. I have and will maintain a certificate of consent to self -insure for Worker's APN Number: 36907019.00 Occupancy Type: Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. 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. PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF RMIT ISSUANCE OR APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is 180 DAYS L ALLED INSPECTION. 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 Iss by: Date: 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 ROOFS: all non -point source regulations per the Cupertino Municipal Code, Section 9.18. All roofs shall be inspected prior to anyy roofing material being installed. If a roof is Signature Date 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER two reasons:wner of the property, or my employees with wages as their soleensation, #thefwing will do the work, and the structure is not intended or offered forHAZARDOUS MATERIALS DISCLOSURE Sec.7044, Business & Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I, as owner of the property, am exclusively contracting with licensed contractors to California Health &Safety Code, Sections 25505, 25533, and 25534. I will maintain construct the project (Sec.7044, Business & Professions Code). compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. I e eby affirm under penalty of perjury one of the following three declarations: Additionally, should I use equipment or devices which emit hazardous air have and will maintain a Certificate of Consent to self -insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation, as provided for by Section 3700 of the Labor Code, for the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & e CoRee 505, 25533, and 25534. performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Owner or or'ze Section 3700 of the Labor Code, for the performance of the work for which this Date:1 O permit is issued. s. I certify that in the performance of the work for which this permit is issued, I shall CONSTRUCTION LENDING AGENCY /hereby 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 affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code, I for which this permit is issued (Sec. 3097, Civ C.) Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. 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 Licensed Professional 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 w ' may �acc: a ag inst said City in consequence of the granting of this pe rt. dition 1[y, the pplic erstands and will comply with upert' o Mu icipal Code, Section 9.18. all non -point sour a re tions :�� Signature Date % p1 SWIMMING POOL I SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 S P (408) 777-3228 •FAX (408) 777-3333 • building (cD-cuoertino.orq a 00 ( 9 _L_ PROJECT ADDRESS , APN i� 3(090 -?o L ej, O -0 OWNER NAME �unG �no�LtvQ, PHONE E-MAIL -252-- zq 3f L- - I STREET ADDRESS ( �o3 3� r-, fes" sr�,c �' CITY ATE, ZIP FAX S>� CONT ACT NAME P �'8 _ D — D� ? E-MAIL ` I STREET ADDRESS CITY, STATE, j1p FAX ❑ OWNER ❑ 01A'NER-BUILDER OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGLNEER ❑ DEVELOPER ❑ TENANT COIN'TRACTOR NAME v o,/yv �- LICENSE NUMBER LICENSE TYPE BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCJ{ITECTlENG[NEERNAME LICENSE NUMBER I BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK r- , f^'S�� dP G G— 5 G USE OF ❑ SFD or Duplex Q Multi -Family TYPE MATERIAL TYPE (CODE) AREA (SQ. Fr.) VALUATION (S) POOL STRUCTURE: ❑ Commercial POOLJSPA MATERIAL TYPE CODES: SPA V - VINYL.-L[NED F - FIBERGLASS DEI.20 tt fi G - GUNITEz: le`j. r , TOT(/ �U J0'i P - PREFABRICATED R CII�tED BY ' �--- i..�. _ n the property owner's behalf. I have read this By my signature below, I certify to each of the follov6ng: I am the property owner or au z mo application and the information I have provid cogect. hav e the Desc ion of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin e nstyG tion. I ori represe tatives of Cupertino to enter the above -identified property for inspection purposes. S ignature of Applicant/Agent: / Date: SUPPLEMENTA FORt�4ATION REQUIRED ' oFFtci, usF oi`Z.Y SLIP - _ Commercial or Multi -Family Buildings with Public Swimming Pools: Department of Environmental Health approval required. •• TT d�� f - hfNG, 'frr• t{ �t ytiy}�•�.`��i'' **' �AlGiJ ,i�•t. �F.P.YD✓L`oi,1/G�L L - tet' t_� Mir f n`.: ;`L�ENVIROIV1vn1T .� , �' *2ti�t .tet :.Y• .bL< t,',[, .1 �F3': '� �a1 S .� _ 1 v` . SwimPoolApp_201 1. doc remised 03/16/11 �� CITY OF CUPERTINO D I��/JI FEE ESTIMATOR -BUILDING DIVISION FEE ID # POOLS 1 DEMOPRES 'I 10336 E ESTATES DR --7DATE: 10/23/2015 REVIEWED BY: MELISSA jigADDRESS: APN: 369 07 019 BP#: 'VALUATION: j$1,000 PERMIT TYPE: Demolition Permit P/.tlN C11h,(W Tt"PL. PRIMARY USE: Swimming Pool, Res. Plumb. Irish. 1 PENTAMATION PERMIT TYPE: 1 SFPOOLDE WORK REMOVE E SWIMMING POOL & FILL FOR LANDSCAPE PURPOSES ONLY SCOPE Suppl. Insp. Fee:Q Reg. Q OT FEE ID # POOLS 1 DEMOPRES 'I NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef.' 7.%1%13) vleol. lUid .ttc:ik :3,.. tc1�f �.sr, �,,, .. i ia;l i /tcc G L1ech. Permit Fee: Plumb. Permit 1``ee: [1-lec. Permit ree: Other Hec h. Insp. Other Plumb Insn. Other 1dec. Insp. 1<lech, Insp. Fee: Plumb. Irish. 1 Elec. Inst:). Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef.' 7.%1%13) FEE QTY/FEE7 MISC ITEMS r')Ian Check I'c'e: ti;uppl. PC Fee Plumb. /11ech./Elec. Permit Fee: $329.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 ''/iinrb %1 fec1t.;`Ele c, Plumb.lWch.%"Elec Permit Fee: (.otastt~uction Tcu: "I. Jininistr otive Fee iVork l� ithout .Peen it? .1dw.i lc ecl Plcinning Pees: A Trovel Docutnenlation Tees: Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item 131da Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $330.50 $0.00 TOTAL FEE: $330.50 Revised: 10/01/2015 i OWNER -BUILDER DISCLOSURE FORM COiAMiUNITY DEVELOPMENT DEPARTNIiENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTiNO, CA 95014-3255 (408) 777-3228 - FAX (446) 777-3333 - build inaecuoortino.ora CUPERTINO I Dear Property Owner(s): property -",n application for a building permit has b:,:.n submitted in your name listing yourself as the builder of the We providing you with an Owner -Builder AcknovJCedgment and informatio nVerincationa e�5oz Ownke er-Build:,ru aware �lh'e W., are p 9 your responsibilities and possible risk you may incur by n`tialethis ourrunderstandinguof each provision, signed, and will not issue a building permit until you have read, Y returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKN0WLEDGfJfENT AND VERIFICATION OF INFORMATION La (DIRECTIONS: Please read and initial each statement below to signi�y you undersor verrry this in�ormafion.) understand a frequent practice of unlicensed person is to�hnva►sh rGV dtngproperty h ner- sowner or h o own �borr ain an and material Builder" building permit that erroneously implies that the prop..rty o pained personally. 1, as an Owner -Builder, may be held liable and subject to serious financnQ � `onet's ir any lnjunsurrance may not an unlicensed person and his or her employees while working on my properly. y provide Coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. �2. I understand_ building permits are not required to be signed by property owners unless they are responsible fOr the construction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an "Owner -Builder" i am the responsible party orrecord on'the-p permit I understand filed in his s or her may protect myself from potential financial risk by hiring a licensed Contract 9 - name instead of my own. understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. engage y p� other than Caiifornia licensed Contractors, and the _5. I understand if l employ or OL Gng a an persons, o� a total value of my construction is at least five hundred dollars ($500}, including labor and materials, I may be considered =n "-mployar" under statz and federal law. tt.. ' r� ' al law, i must register with the state and 7c, 6. 1 understand if 1 am considered an employer" under state anQ iedera , f: dere) government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." l also understand my failure to abide by these laws may subject me to serious financial risk. 7. i understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legal)}� build them with the intent to offer them for sale, unless all work is perormed by rc licensed subcontractors and the number of structures does not exceed .our within any calendar year, or all of the worn uilding Contractor. is perormed under contract with a licensed general b issued, I may be held liable for 8. I understand as an Owner -Builder if I sell the property for which s Ithahis pers �ltiS om any late t construction any financial or personal injuries sustained by any subsequent o�� n (} -- defects in the workmanship or materials. O,ynerguila'erForm 2010. doe revised 04114110 T��` 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or vrvn►v.cslb.ca.gov for more information about licensed contractors. - X10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that f am the party legally .and financially responsible for proposed construction activity at the sit= address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, { �f✓i!1 wide by all applicable laws and requirements that govern Owner -Builders as well as employers. Tc-- i2, I agrees to notify the issuer of this form immediately of any additions, deletions, or changes to any of 'the ecttha.public. If information l have-proviaed on this f .. orm. Licensed contractors are regulated by-laws designed to pro you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a. result of a complaint.. Your only remedy against unlicensed Contractors may, be in civil court. It' is also important for you, to understand that if, an unlicensed Contractor. or _ employee of that individual or firm is injured .while working on your property, you may' be held liable for damages. If youobtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors- are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented ivhen the permit is issued n verii%, the oropen`y owner's siansture. I , Property Owner's Signature: Date: --------------------------------------------------- ------------------------------------------ --- (NT E: The foilotving Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sian, and file the documents necessary to obtain an Owner -Builder Permit for my project.` t Scope of Construction Project (or Description of Work): + 111L er•.�'t "� S�^''- � �p" � �''�� Project Location or/ ddress: 1033 (�, P --- o s ��s D 1, Name of Authorized Agent: --arc^ �� Tei No Address of Authorized Agent: 03% � Jr, Dr. soy I declare under penalty of perjury that i am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy or the property owner's driver's license, form notarization, or other verification acceptable to the city may 6 fired ` b present d when the permit is issued to veriy the property owner's signature. _f� � � i �----- Proper'.y Owner's Signature: Date: / d -?.��`S G4nerBuilderForm ?010.doc revised 0411 "/10 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS:�e- PERMIT # J'7 c Q / 2 -- OWNER' S NAME: ` r. PHONE #�. iL�1,3 GENERAL CONTRACTOR: D (JA f3 (� rZ— BUSINESS LICENSE # ADDRESS: X, CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCO CTORS OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date, Pleasecheck applicable subcontractorand complete the following information: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date 1 - d� �` CUPERTINO Building Department }} r4. ; r. �. ',�, �� l �� _.�, L.... OCT 2 3 2015 r REVIEWED FOR CODE COMPLIANCE r J N1UNITY PMENT DEPARTMENT COI'v1 BUILDING DIVI ION - CUpERT1N0 QVE� BY "�,� APP h t at the This set of plars a spe fi: at�ons {l� GlUto make any job site dur,ng" construct, n. It �s u changes or alterati:� on sa'z1e, or d° dOffiCiae. r" therefrom, withcut app r a, prom ,he Bu 9 f m o`' is pian nd specifica' ons SHALL NOT 14,49et TheStamp 9 O proval of the violation to permit Law.,na;;ce or State of an FFICE C PY fJ i