13100054 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10842 LEAVESLEY PL CONTRACTOR:PHILLIP D.BJURMAN PERMIT NO: 13100054
OWNER'S NAME: IYER SUDHA K 1250 HIGHWY 101 DATE ISSUED:10/07/2013
OWNER'S PHONE: 4089961099 AROMAS,CA 95004 PHONE NO:(650)906-7533
�� LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class_ Lic.# W 7 REMOVAL OF SFDWL POOL 416 SQ FT
Contractor ��'0` Date �G
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:$7000
I hav and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this APN Number:35615034.00 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 W DAYS OF PERMIT 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=M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the `(� 7
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
n RE-ROOFS:
Signature / Date 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-BUH,DER DECLARATION
I hereby affirm that I 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)
I,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
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
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 of the 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 Cod Mns ,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized age
permit is issued.
I certify that in the performance of the 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 of the 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
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O
CUPERTINO (408)777-3228•FAX(408)777-3333•buildingp_cupertino.org 1 `
PROJECT ADDRESS APN#• ! 'w lactI��`/ 1/C
OWNER NAMES t j& �� PHONE q�0_ ( b 1 qq �/ E-MAIL
STREET ADDRESS 5;1,�'rnjcf- CITY,STATE, ,`�IP I v 6 FAX
CONTACT NAME PHONE C� E M IL
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER-BUILDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRA fl1N^A`N ICENSE VIER LICENSE PE BUS.LIC#
rlCllr `� �GZ
COMPAN}CjJ�MA ! / \ n`t EMAIL FAX
XQL
STREET (ADDRESS +J CITY,STATE ZIP P ONE ^ Q Y
3 a A�� L)4-- 7 YY�� (� A r �Jti i 33
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
D S"I JYtp✓lI 1`�'C��
USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S)
STRUCTURE: ❑ Commercial POOL
POOUSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DEMO
G - GUNITE
P - PREFABRICATED i TOTAL VALUATION:
k, °
By my signature below,I certify to each of the following: I am the property owner or autho zed 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 relati n ction. I auOvori4 representatives of Cupertino to enter the above-id tified property for inspection purposes.
. 1 f� 3
Signature of ApplicanUAgent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
Commercial or Multi-Family Buildings with Public Swimming Pools: a�, ;
Department of Environmental Health approval required.
A
SwimPoolApp_2011.doc revised 03/16/11
CITY OF CUPERTINO D
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10842 leavesly pi DATE: REVIEWED BY:
APN. BP#: *VALUATION: 1$7,000
*PERMIT TYPE: Demolition Permit PL4N CIII;CK 7'YPE:
PRIMARY Swimming Pool, Res. PENTAMATION 1SFP00LDEM
USE: PERMIT TYPE:
WORK I sfdwl pool removal
SCOPE
FEE ID #POOLS
1 DEMOPRES 'I
WO
�"M y ..
�r
Xfech. flan('leek Plumb.Plan Check Elect.Plan Check
;Ltech.Permit Fee: Plumb.Permit l=ee: flee. Permit Fee:
Other Alech.Insp. Other Plumb Insp. Li Other Elec.Insp. Li
laech.Insp.Mize: Plumb. Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1113) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
Plum b.lillfech./Elec
Permit Fee: $319.00
Suppl. Insp.Fee-.0 Reg. ® OT 0,0 hrs $0.00
Plumb./Mech./Elect
Plumb./:11k,ch./Elee Permit Fee:
Construction :Tax:
Administrative.Fee:
Work. Without Permit?
Aelvanczed Plartning Tees:
Travel Documentation Fees:.
Strong Motion Fee: IBSEISMICR $0.70 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$320.701 $0.00 E•_ $320.70
Revised: 10/01/2013
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REVIEWED FOR CODE COMPLIANCE
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