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B-2016-2458i' CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-2458 20800 VALLEY GREEN DR CUPERTINO, CA 95014-1735 (326 09 040) PACIFIC SURFACING INC FREMONT, CA 94539 OWNER'S NAME: 20800 VALLEY GREEN DRIVE DATE ISSUED: 04/13/2017 OWNER'S PHONE: 408-253-0200 PHONE NO: (510) 440-9494 LICENSED CONTRACTOR'S f TOR'S DEC A A ATION BUILDING PERMIT TWO: License Class A: C-8: C-32 Lic. #657394 Contractor PACIFIC SURFACING INCDate 10/31/2016 X BLDG —ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH _ RESIDENTIAL X COMMERCIAL — — with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REMOVE AND REPLACE (E) CONCRETE POOL DECK (7575 S.F.) 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 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. i. j'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: $94000.00 APPLICANT ANT RTIFI ATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 326 09 040 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. Additionally, the applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal ode, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. -Signature -- Date 4/13/2017 Issued by: Abby Ayende OWNERM-m- Date: 04/13/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the 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) i. I, as owner of the property, am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 4/13/2017 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 2. 1 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. I 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 stir contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of 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, Sections 25505, 25533, an 5534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. r - Owner or authorized age�- APPLICANT CERTIFICATION v Date: 4/13/2017 I certify that I have read this application and state that the above information is CTION LEND ID7 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 4/13/2017 Professional 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 • building0cupertino.orp --2�V(fi V PROIECTADDRESSAPN n \lcalle Greew�rov # 32� Oaty 54f O� j�ERNAME ,,_ t PI•IONE �I Gt+� Q.t�t �}1Rj r jiVl 4 O ' �S "V E-MAIL STREET AD RES9pAX CITY, STATE, ZIP CONTACT NAME � U V, t,•� �0 PHONE 25 Zrt� E-MAIL �� a STREETADDRESS C-sS'ee%A _D ` CITY STATE, Zlp C �° ` X5' !4 FAX wtw- - io2 ❑ OWNER ❑ OWNER -BUILDER -OWNRRAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT 13 ARCI-IITECT ❑ ENOINEER ❑ DEVELOPER ❑ TErtlANT CONTRACTOR NAME �}�� @ 1�- r l� LICENSEENNUMMBER ACENSETYPE BUS. LIC 9 COMPANY NAM�'r�-/y t ��e. E-MAIL 141Vk •`LVAk it OTT C r- t FAX l tt~ 1. rcowl- STREET ADDRESS 1.���i S:tfiuw CITY, STAT t L y 'i PHONE hRCII1TECTIENCINEER N LICENSE, NUMBER BUS: LIC #�C'� COMPANY NAME E-MAIL FAX Cts Wi � STREET ADDRESS a,N z. fit`` Skc�- CITY, STATE, ZIP S� e1s oq PHONE --3sb1 DESCIUPTION"OF°WORK---_ 1 S USE Or ❑ SFD or Duplex ❑ Multi -Family TYPE MATERIAL TYPE (CODE) AREA (SQ. PT.) VALUATION {$) STRUCTURE: 9/Comimercial POOL POOLISPA MA'IMIZIAL TYPE CODES: SPA V - VINYL -LINED DEMO P - FIBERGLASS G - GUNITE RECEIVE[) BYr :: "::.` :.:".:.: - - �[a TOTAL VALUATION: I' - PREFABRICATED Ry my signature below, I certify to each of the following: I am the property Owner Or autboriz d agent tb act on the property owner's behalf, I have read this application and the information I have provided is correct. I Dave read the D ri 'on of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building c I sitatives of Cupertino to enter the aUovg i0entifil property for inspection purposes. Signature of Applicant/Agent: Date: �i3f (f tii SUPPLEMENT FORMATION RFAIRED O F10E:USE:\LY .... .._ .. -, :.:::...... PL 4V"QkIECK=YPE.:'(is'; ;, ROi7TINGSIIP`'5=:i!s.: _ Commercial or Mult1-Fatally I3ulldrngs with Public SWlmnun8 Pools: -".• ............:_......,.-- TUE-COUNTFIt._;s; .. ,,,--.:.:::.: ...::,.:..,._:� :<::: _::: Depo,'.onmentaapproval required.❑�":OVER t tment.of Environmental Health l -i ;:B"U[F:DTII,GDEPT_:'`:''.'.':.'';_�;•`:'t�_tss: ---- EXPI2ESSPLAllI1Ii�C•DElvp `EI3VIit©NAfE1vTAI HEALTH" == : .:....-..:-;". y .... ❑ I4L,JOR` i ..F<p; `:i:•:Si.-%`�i%ss,.�;FY?i '.::,t'''i -"•=fir: % `:: _ •_:_;'„S.At1I1'AItY:3E1VERDISTRIGFT��;:.:[ SvvfmPooL4pp_ 011. doe Devised 03116/11