Application & Fee Est. for B-2016-0360CUPERTINO
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 S P
(408) 777-3228 • FAX (408) 777-3333 • buildingOcupeltino.ora
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PROJECT ADDRESS
APN A 776 r % 5 — CZ 7
OWNER NAME
PHONE.
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
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FAX
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CONTACT NAME
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PHONE
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B-MAIL
STREET ADDRESS
CITYST , ATE, ZIP
PAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT
.,CONTRACTOR ❑ CONIRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
SENUMBER
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LICENSETYPE
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BUS, UC0 A J 5 S
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COMPANY NAME
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E-MAIL
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FAX
STREET ADDRESS
CITY, STATE, ZIP
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PI{ONE
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ARCFETECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC N
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, Z[P
PRONE
DESCRIPTION OF WORK
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�.¢ P Y �� /Cy /.7 ✓.ram �-s/a ^^- a o-%v/ CI✓h t re ✓✓�!
bI,e
o re O- /
❑ SFD Or Duplex ❑ Multi-Family:SPA
PE TYPE (COOL)
AREA (SQ. FT.)
VALUATION ($)
USE OF
OL
STRUCTURE: ❑ Commercial
POOIJSPA MATERIAL TYPE CODES:
LMATERIAL
V - VINYL-LINEDMF
-FIBERGLASS
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f
REC D TO
P -- PREFABRICATED
GVALUATIOcFi
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By my signature below, I certify to each of the following:
I am the property own o_f 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 relatinto buildi�nstZ
I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofAppli...... ant: `1EGl
Date:
SUPPLEMENTAL INFORMATION REQUIRED
` P AIDiCKTYPE
•PROUTA'GSLIP •`
Commercial or Multi -Family Buildings with Public
Swimming Pools:
T»couNTex
O R'tI[LnlNcn>•:er
Department of Environmental Health approval
required.
vExi
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❑ EXPRESS �-
-T'
o❑�ANN>NGD
❑ STARD
Y❑�' PUHLIC WORKSDEPT > `•:
❑ LARGE '� '��
❑ ENVIRONMEN��.REALT�� � '.
�,YMA.TOR z...._ -x`�. �,
+�O.SANITARY SE}VER DISTRIGP
SwimPoolApp_2011, doc revised 03116111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21903 WOODBURY DR
DATE: 01/1912016
REVIEWED BY: MELISSA
APN: 326 39 023 BP#:
'VALUATION: $5,000
*PERMITTYPE: Demolition Permit
l'i,INCtHE 7Yt'F_°.
PRIMARY Swimming Pool, ReS.
PENTAMATION 1SFPOOLDEM
USE:
PERMIT TYPE:
WORK
DEMO/FILL E SWIMMING POOL & FILL FOR LANDSCAPE PURPOSES ONLY
SCOPE
;tfe(:1F. Plan E'�"treeh
Ylunrh. Pico? ('hcek
E{ec. C'l:fn Check
�fi�-CIF, Porma fa,?:
flc,wb. Pf.9mit fee.
glee. Pvtw Ft Pee-
0"h rNoah. Lash
Ofher llIrmrt>Inch.
other Iraec. br"yr.
.'iferh, Imp.
Phunn. lnq' ' Pee:
L;Ien Imp-
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Eire, Sanitary Sewer District, School
Dtctrirt. PtrJ. Theca fens are haled on the nreliminary information available and are onlv an estimate. Contact the Dept For addn'l info.
FEE ITEMS (Fee Resolution II-053 EfE 7/l/W
FEE
QTY/FEE
MISC ITEMS
Plan ChecA Fee:
SrppL FC:".Fee
Pd trrrtb.:'"ri�leeh.%F'lec
Permit Fee:
$329.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
lirs
$0.00
E l rant fr.: ":19ee h.;'G t et;
Pit€rh.;511eG"h.-llecl erinivFee:
"Ons i ucl iun S b x
Admill€sh-alive Fen.
Work Willwail Permit?
A(Jvancetl Planmft6y Fees:
A
Dwvel Documentation Fees;
Strong Motion Fee: 1BSEISMFCR
$0.65
Select an Administrative Item
Bldg Stds Commission Fee: tBCBSC
$1.00
SUBTOTALS:
$330.65
$0.00
TO CAL FEE :
$330.65
Revised: 01 /01 /2016