B-2016-2118 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2118
10161 PHAR LAP DR CUPERTINO,CA 95014-1113(326 39 056) GREEN LINE
DEVELOPMENT INC
CAMPBELL,CA 95008
OWNER'S NAME: MAIER JOETTAAAND DANIEL S DATE ISSUED:06/13/2016
OWNER'S PHONE:408-836-5828 PHONE NO:(408)215-8007
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#975092
Contractor GREEN LINE DEVELOPMENT INC Date 07/31/20.16 X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
INSTALL PRE-FABRICATED IN-GROUND SPA AT REAR(8'X20')
I hereby affirm under penalty of perjury one of the following two declarations:
r. 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 Cade,for the
performance of the work for which this permit is issued.
z. 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. Sq.Ft Floor Area: Valuation:$6500.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 326 39 056
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITIIIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all'non-point
source regulations pert Cuperf no Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date ft (3�� Issued by:PhuongDe ies
Date:06/13/2016
OWNER-BUILDER DECLARATI N
I hereby affirm that I am exempt from the Contractor's License Law for one of the "
following two reasons: i All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for / inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&,Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If,after making this certificate of 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
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Section 55 ,255 nd 25534.
Labor Code,I must forthwith comply with such provisions'or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date Professional
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 S P
+CUPERTINO (408)777-3228• FAX(408)777-3333•building(cDcupertino.org
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PROJECT ADDRESS ID APN#1
OWNER NAME j PHONE ®e n /1 p/Q E-MAIL
STREET ADDRESS ,/ r CITY, STATE,ZIP(,- rIn qpS� L� FAX
CONTACT NAME r PHONE E-MAIL
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STREET ADDRESS 2-7,31 S F20-S60M (2CITY,STATE,ZIP / FAX
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CONTRACTOR NAME ell
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DESCRIPTION OF WORK ^ qq I
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USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION (S)
STRUCTURE: ❑ Commercial tp(� --�o,c-, 0 / 0 615-00 00
POOL/SPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO
G - GUNITE
RECEIVI Bl T ALNgLUAUO1
- PREFABRICATED J S(
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By my signature below,I certify to each of the following: 1 am the prope> ow leor aut _ i d agent to act on the property owner's behalf. I have read this
application and the information I have provided is co ct. I ave read i he Descrl f and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildin n ctio aut representatives of Cupertino to enter the//above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: [� `7 3 I
SUPPLEMENTAL INFORMATION REQ IREDoFric>-us EON
Lv
PLAN CIiECK TYPE * ROi7TING SLIP,
_Commercial or Multi-Family Buildings with.Public Swimming Pools:
Department of Environmental Health approval required. ❑ ovE�t THE courrrER > ❑ Bt1ILDINc WEPT
D
❑%EaPRESS , PLAN\ING�EPT
❑a STANDARD ❑ PUBLIC WORKS DEPT
❑:LARGE:•` I � ❑-E\VIRONMENTAL HEALTH �
�-%,MAJOR,_ ;'.• r ❑:SANITARI'SL\VEIi Di57 RiC
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SmintPoolApp_2011.doc revised 03/16/11