14030003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING.ADDRESS: 21820 MONTE CT CONTRACTOR: DOUGLAS LANDSCAPE PERMIT NO: 14030003
CONSTRUCTION, SNC
OWNER'S NAME: MARIE KLEMCHUK 1891 ALMADEN RD DATE ISSUED:03/03/2014
OWN'ER'S PHONE: 4085066133 SAN JOSE,CA 95125 PHONE NO:(408)445-2620
�$ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
G 8"3 C C-1.7 C tq INSTALL(N)SWIMMING POOL& SPA &FIRE PIT(NEW
License Class Lic.# DESIGNATED GAS LINE)
" CowSmcomi-
Contractor py►t*14gS �-I4tnd9CAP!C Date 7-3-14
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.
I hereby affirm under penalty of perjury one of the following two declarations:
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. Sq.Ft Floor Area: Valuation:$85000
L!.Iiave and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the performance ofthe work for which this APN Number:32619083.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS O ' RMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY ALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence ofthe
granting of this permit. Additionally,the applicant understands and will comply Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18,
RE-ROOFS:
Signature Date 3 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.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that[am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
4 declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
1 Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area.Air Quality Management District I
performance ofthe work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 ofthe Labor Code,for the performance ofthe work for which this
a Owner or authorized agent: Date:
permit is issued.
EI certify that in the performance ofthe work for which this permit is issued,I shall
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions ofthe Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
Y
4
i APPLICANT CERTIFICATION Lender's Address
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 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
t
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence ofthe 1 understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
i with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
SWIMMING POOL / SPA PERMIT APPLICATION O
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
�O
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 �4
CUPERTINO (408)777-3228• FAX(408)777-3333• building(d),cupertino.org \
PROJECT ADDRESS,A'7 I
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OWNERNAME LA •1- f — G /`� G PHONE d _ ` E-MAIL
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STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME -71 PHONE E-MAIL
STREET ADDRESS ,/v F, CITY,STATE, ZIP 7/4N S0 C FAX qV L,T+60
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT r-� CONTRACTOR 1:1 CONTRACTOR AGENT El ARCHITECT 1:1 ENGINEER El DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE �'1j't BUS.LIC#
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COMPANY NAME E-MAIL FAX
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STREET ADDRESS CITY,STATE,ZIP PHONE
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ARCI-UT&FIENGINEER NAMBt�"" LICENSE NUMBER BUS.LIC#
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DESCRIPTION OF WORK
1 h.k a I-xiad s .a P 4z
S 'P"Or,e Jt-
USE OF SFD Or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION (S)
STRUCTURE: ❑ Commercial POOL
POOLSPAMATERIAL TYPE CODES: SPA
V - VINYL.LINED (62
F - FIBERGLASS DEMO —_
G - GUNiTE
P - PREFABRICATED RE C ,a,.e.,..,,,.,'�.,; - TOTAL VALUATION:
Do
By my signature below,I certify to each of the fo ' g: I am the rty o r or a t on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Des Ion of Work and verify it is accur ree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identifie p perty for inspection purposes.
Signature of Applicant/Agent: Date: 3—
SUPPLEMENTAL
—SUPPLEMENTAL INFORMATION REQUIRED Q OFFICE USE ONLY
PLAN CHECK TYPE ROUTING SLIP
_Commercial or Multi-Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required. OVER-THE-COUNTER ❑ BUILDING DEPT
❑ EXPRESS ❑ PLANNING DEPT
❑ STANDARD ❑ PUBLIC WORKS DEPT
❑ LARGE ❑ ENVIRONMENTAL HEALTH
❑ MAJOR ❑ SANITARY SEWER DISTRICT
SwimPoolApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21820 MONTE CT DATE: 03/03/2014 REVIEWED BY: MELISSA
APN: 326 19 083 BP#: l � � �3 'VALUATION: 1$85,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION RBSP
USE: PERMIT TYPE: A
WORK INSTALL N SWIMMING POOL & SPA & FIRE PIT NEW DESIGNATED GAS LINE
SCOPE
Plumb.Plan Check 0.0 hrs $0.00
FT
Plumb.Permit Fee: IPPERMIT _=r
-; Other Plumb Insp. 0.0 hrs $47.00
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc.). These,fees are based on the prelimina information available and are on an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Ef" 711 13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 576 s.f. Swimming Pool
Suppl. PC Fee: 0 Reg. Q OT 0.0 hrs $0.00 $1,528.00 IPOOLGUNIT Gunite
PME Plan Check: $0.00 1 # Plumbing
Permit Fee: $0.00 $70.00 IPGASRES Piping, Gas <=4 Outlets
Suppl. Insp. Fee:Q Reg. Q O $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
t owF l ucnon 7"1v
Administrative Fee: IADMIN $44.00
Work Without Permit? Q Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRA VDOC $47.00 Building or Structure
A
Strong Motion Fee: IBSEISMICR $8.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $4.00
SUBTOTALS: $150.501$1,598.00 TOTAL FEE: $1,748.50
Revised: 01/15/2014
Building Department
City Of Cupertino
Lis 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RTI N O Fax:408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: Z/ PERMIT# D ODO 3
OWNER'S NAME: PHONE# .9b 6
GENERAL CONTRACTOR: JcL4 L*4%4tc BUSINESS ICENSE#
ADDRESS: 1 2�]• 5 l'z 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
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