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CITY OF CUPERTINO
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!Ci�1�i�I2AC'TOR�INFORMATIOMe't:
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.0 5 060129
2830 SAN JUAN RD
NAME:
PERMIT ISSUE DATE
aR'S
GARYQUEEN
10/06/2005
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
o
Job Description
1 hereby affirm Nal 1 are licensed under provisions of Chapter 9 (commencing
P
with Section 70010 ofDivaion 3 of Ne Business and Profesdam Code. and my license is
In full tome and affect.
ADD POOL HOUSE W/BATH & COOKING AREA
License Class Lic. k
Dem Contractor
ARCHITECTS DECLARATION
1 understood my plans Nall W Used an public meet&
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for Ne
fallowing ..on. (Section IID I.S, Business and Profession Cc&: Any city ar county
which requires a permit w construct. alum, Improve, demoilah, or repair my stranule
$100000
prior at do issuance, also mquims Mc applicant forsuch permit la file a signed statement
Sq. Ft. Floor Area
Valuation
Nat he is licensed Pursuant to the pnvislonsef the Common's Limm. Lsw(Chapter 9
(commencing with Section 7M) of Division 3 orlhe Business and Professions Code) or
that he Is eampt therefrom and Use basin for the alleged exemption. Any violation of
-3 3W p9wWr-U0
Occupancy Type
Secdon 7011.5 by tory applicant for a permit subjects the applicant w a civil penally of
not mom that, five handled dollars (M).
❑ I, as owner oldie property, or my employees with wages as their mle compensation,
Required Inspections
will do the work and the stractues lsnmimemled MoRomA I ..We(Sm. 7044, Business
and Professions Code: The Contractors License Law does not apply m ner an owor
9 P
property who builds or improves thereon, end who does such work himself or through his
own employees, provided that such improvements as not intended or offered forsale. if.
however. Ne building or Improvement Is mid within one year of completion, the owner.
builder will hes the burden of proving that M did not Wild or improve fur purpose of
cele.).
591. as owner of the property, am exclusively cantrmting with licensed comtramms to
convect the protect (Sec. 7044, Business and Professions Cade) The Conumur's Li -
came law dna nal apply to an owa" of property who Wilds ar improves Names, and ,
who contracts for such projects with a contractor(a) licensed pursuant u the Counselors
License Law.
❑ 1 am exempt under Sec. . B & P C for thh mases
•r �+.w�. f Dam I .. / 4./s t
WOR 'SCO PENSATIO ECLARATION
I Mmby affirm under penalty of perjury one of the following deduallom;
❑ I ham and will maintain a Certificate of Consent to self-inmee rm Wotker'sCampen-
sNon, as provided for by Section 3700 of the labor Code, for the Performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation lasurance, As mquired by Section
37W of Ne labor Code. for the performance of Ne work for which this permit Is issued.
My Worker's Compensation Insurance carrier and Policy number me:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed hilae permit is foramhundrod dollars ($1010
or toss.)
1 coolly Net in the performmce of the work for which this Permit 4Issued. I shall not
employ any person in anymann-r 4w�c�me subjcnu Me Workers' Compensation
Laws ofCalifornia. Date
Applicant
NOTICE TO APPLICANT: I aaRcr making thlis eomfmale of Exemption, you should
become subject to the Workers Compensation previsions or Ne labor Cade, you MUM
forthwith comply with such previsions or this permit shall W deemed revekod.
CONSTRUCTION LENDING AGENCY
I hereby affrm that thea Ise construction lending agency for Ne performance of
the work for which this permit Is Issued (Sec. 3097, Civ. C.)
'
Lenders Name
,
-
Lenders Addmo,
I «rtify that I have road Nis application and suis that the above Informetiun is
correct. I agree to comply with all city and county ordinances, and suis laws solacing to
building construction, and hereby authorial mpresenuciwa of this city to enter upon Ne
above-mentioned Pmpeny for WFemlao purpua
(We) agme to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments. Cosa and expenses which may in any way menet agaimtsaid Clly
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs �fy�,7�f
Type of Roof
st,!e/
Signetum afAppliAlfuCo r�w, me
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or run= building oceupant nom or Media humdous material
m deflud by the Cupertino Municipal Code. Chapter 9.13. and the Health and Safely
^, Section 25532()?
All roofs shall be inspected prior to any roofing material being installed.
[I You MN.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fuwm Wilding aceupant me equipment or devices which
AMU hrrandous air canmminanss m &Recd by Ne Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes 1KNu
I have mad the haaardousmeurials requirements under Chapter6.95 of the Califor-
Me Health & Sa@ry Cade.Seedom 25505.25533 and 25534.1 undeuuM NLLirue building
does not currently have a Imam, dist It Is my responsibility to notify Ne acupanl of the
requirements which meet W met prior to Immune of a CcrtiBcau of OcmPancy'
Signature Of Applicant Date
E� ft. Ie / e / s
All roof coverings to be Class "B" or better
Owner orauthab agcor Dam
L
CITY OF
CUPEkTINO
CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN #
Fee Description
Fee Group
Date:
3 y -2-- 2 /-
MECHANICAL
BBOILERI
/ o oS
Building Address:
BBOILER2
Mailing Address (if different from building address):
2 er n
C. G A 9ro �
Owner's Name:
BBOILER4
Boiler > 1M to 1.75 M Btu
Phone #:
C e- .+ c c
Boiler > 1.75M Btu
MECHANICAL
Jy C>- 4- 2
Contractor:
BUILDING
BCONSTAX
License #:
Contact:
Phone:
Con. Tax for BQ Zone
Cupertino Business License#:
BCONSTAXH
Fax:
BUILDING
BCONSTAXR
Building Permit Info:
BUILDING
BELEC 1000
Bldg �O Elect ®
ELECTRICAL
Plumb 0 Mech.X
Job Description: G. -I �, ►... ,,,
a.., d c o ..ti
V o. P *_�
Residential X n o o -X
s
,, Commercial ❑
Sq.Ft. Floor Area: g o o s ,;�
�, .. d
BENERGYADD
$/Sq.Ft.:
S
e
d 00 e.
T
Cost of Project:
Occupancy Group:
T a P
Type of Construction:
Please check this box if the project is a
second -story addition: ❑
Project Size: Standard Large ❑
Major ❑
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBOILERI
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler > 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 500K to 1 M Btu
MECHANICAL
BBOILER4
Boiler > 1M to 1.75 M Btu
MECHANICAL
BBOILER5
Boiler > 1.75M Btu
MECHANICAL
r BCONSTAX
Construction Tax
BUILDING
BCONSTAX
Ind/Off/Comm/Quasi
BUILDING
BCONSTAXBQ
Con. Tax for BQ Zone
BUILDING
BCONSTAXH
Hotel and Motel
BUILDING
BCONSTAXR
Constax — Resi/Mobile
BUILDING
BELEC 1000
Elec 600V <= I OOOA
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
1 of 3 I
FY OF CUPERTINO
BUILDING DIVISION PEI_
BUILDING ADDRESS:
22830 SA
OWNER'S NAME:
CARY
PHONE:
ARCHITECT/ENGINEER:
u O O LICENSED CONTRACTOR'S DECLARATION
1 hcrcby affirm that 1 am licensed under provisions of Chapter 9 (commencing
Z with Section 700(1) of Division 3 of the Business and Professions Code, and my license is
a o. in full force and effect.
License Class Lic. p
•- p Date Contractor
t
ty ARCHITECTS DECLARATION
Y oe a 1 understand my plans shall be used as public records
DWU
iU. O N Licensed Professional
N OWNER -BUILDER DECLARATION
�- I hereby affirm that 1 am exempt frum the Contractors License Law for the
00 following reason. (Section 703 1.5, Business and Protcssiuns Code: Any city or county
K (Li which requires a permit to construct, alter, improve, demolish, or repair any structure
Z y prior to its issuancc, also requires the applicant for such permit to fhlc a signed statement
a that he is licensed pursuant to the provisions of the Con«actur's License Law (Chapter 9
f=o
z h (commencing with Section 7000) of Division 3 of the Business and Professions Cafe) or
i that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. IL
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
J, 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense taw does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a comractor(s) licensed pursuant to the Contractors
License Law,
❑ 1 am exempt under Sec. , B & P C for this reason
Owner-...r+_..r a.. .z_. Dare 1 2/61prT
WOR1 •R'S COMPENSATION EC ATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ [have and will maintain a Certifhcatc of Conscnt to self -insure for Workcr'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that in the perfotmhance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to comp subject to the Workerz Compensation
Laws of California. Date .� .0 cy to ,S
Applicant
NOTICE TO APPLICANT: 1 , after making this Ccnifiwtc of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
F•.I hereby affirm that there is a construction lending agency for the performance of
R; -the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lender's Name
�
Z
Lender's Address
U Q I certify that 1 have read this application and state that the above information is
U. '--' correct. 1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction• and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
O. (We) agree to save, indemnify and keep harmless the City of Cupertino against
'Fy fol liabilities,judgmcnts, casts and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Appli t/Con tractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)?
El Yes J4No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District?
❑ Yes KNu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not curmmly have a tenant that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuancc of a Certificate of Occupancy.
Owner or authorizt4fagenl Dam
PERMIT NO. 05060129
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
ADD POOL HOUSE W/BATH & COOKING AREA
q. Ft. Floor Area
Required Inspections
Issued by:
Re -roofs
Type of Roof
100000
Valuation
Occupancy
Date i -- 6,- J Lf -
66' _rcl__6 I
f-
6'-rcl__6,
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 "B" or better
02/10/2006 13:30 FAX 650 494 0508
LIFETIME POOLS INC 2001
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
C-) 1-2-'N C L7WI-IAI );?D
IPER IrF # D �a
OWNER'S NAME: Y Q j E C5. /V
PHONE # IF IF 2- u 6- 4 7 If
GENERAL CONTRACTOR L i F— i f /N
FAX # -, p q ¢`1-t_Ds a
I am not using any subcontractors:
gnature Date
PIease check applicable subcontractors and c mplete the following information
ontractor Signature Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
C ent Finishing
Electrical
OO
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Omamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
`� l� s �i✓C
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ontractor Signature Date