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15100138CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22490 PALM AVE CONTRACTOR: KIM JI S PERMIT NO: 15100138 OWNER'S NAME: KIM JI S 22490 PALM AVE DATE ISSUED: 10/16/2015 OWNER'S PHONE: 4086912000 CUPERTINO, CA 95014-2710 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ POOL DEMO (325 SF) License Class Lic. # Contractor Date 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. Sq. Ft Floor Area: Valuation: $2000 I hereby affirm under penalty of perjury one of the following two declarations: APN Number: 35704011.00 Occupancy Type: 1. 1 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. 2. 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 EXPIRES IF WORK IS NOT STARTED permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION. 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 ](3)[1. to building construction, and hereby authorize representatives of this city to enter Issued by: Date: 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 may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with ROOFS: all non -point source regulations per the Cupertino Municipal Code, Section 9.18. All roofs shall be inspected prior to anyy roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for Signature Date inspection. Signature of Applicant: Date: OWNER -BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I ereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE compensation, will do the work, and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the sale (Sec.7044, Business & Professions Code) California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain 2. 1, as owner of the property, am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & construct the project (Sec.7044, Business & Professions Code). Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will I have and will maintain a Certificate of Consent to self -insure for Worker's maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Compensation, as provided for by Section 3700 of the Labor Code, for the Health & Safety Code, Sections 25505, 25533, and 25534. performance of the work for which this permit is issued. Owner r authorized agent: 2. I have and will maintain Worker's Compensation Insurance, as provided for by Date: ('01101 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. CONSTRUCTION LENDING AGENCY 3. 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 I hereby affirm that there is a construction lending agency for the performance of work's Compensation laws of California. If, after making this certificate of exemption, I for which this permit is issued (Sec. 3097, Civ C.) become subject to the Worker's Compensation provisions of the Labor Code, I Lender's Name must forthwith comply with such provisions or this permit shall be deemed Lender's Address revoked. ARCHITECT'S DECLARATION APPLICANT CERTIFICATION I understand my plans shall be used as public records. 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 Licensed Professional to building construction, and hereby authorize 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 may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature �' Date r� CUPERTINO SWIMMING POOL / SPA PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinq(aD_cupertino.orq SP PROJECT ADDRESS ' � U� APN # OWNER NAME _ PHONE _)Zjy/8. `jj�� E-MAIL STREET ADDRESS �7�j Q • f/ J Pa--0�1 CITY, STATE, ZIr � Z� FAX CONTACT NAME �, i �rn PHONE ) / E-MAIL FSTREETADDRESS /, IM CITY, STATE, ZIrc; e e, 4 W FAX OWNER E3OWNER-BUILDER❑ OWI�'ER AGENT El CONTRACTOR ❑ CONTRALTO AGENT ❑ ARCHITECT [:]ENGINEER DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE CT/ENGINEERNRMELICENSE NUMBER BUS. LIC # Y NAME E-MAIL FAX ADDRESS CITY, STATE, ZIPPHONE TION OF WORK 3 2� F USE OF ❑ SFD or Duplex ❑ Multi -Family TYPE MATERIAL TYPE (CODE) AREA (SQ. FT.) VALUATION (S) POOL STRUCTURE: ❑ Commercial POOUSPA MATERIAL TYPE CODES: SPA V - VINYL -LINED F - FIBERGLASS DEMO G - GUNITE P - PREFABRICATEDRECEIVED BY:, - a TOTAL UATION: 1120 By my signature below, I certify to each of the following: I am the property owner o th e 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 relating to building constru tion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: G z Date: ©f SUPPLEMENTAL INFO A ION REQUIRED OFFICE USE ONLY PLAN CHECK TYPE ROUTING SLIP El OVER-THE-COUNTER El BUILDING DEPT Commercial or Multi -Family Buildings with Public Swimming Pools: Department of Environmental Health approval required. El EXPRESS ❑ PLANtiLNG DEPT ❑ STANDARD ❑ PUBLIC WORTS DEPT ❑ LARGE ❑ ENVIRONMENTAL HEALTH ❑ MAJOR ❑ SANITARY SERER DISTRICT Sw imPoo lApp_201 1. doc revised 03/16/11 � CITY OF CUPERTINO D Irml FEE ESTIMATOR -BUILDING DIVISION FEE ID # POOLS 1 DEMOPRES 'I ADDRESS: 22490 Palm Ave DATE: 10/16/2015 REVIEWED BY: Phuong aleck. Perrrtrt Fee,- APN: 357-04-011 BP#: *VALUATION: 1$2,000 PERMIT TYPE: Demolition Permit Other Elec. Insp. PRIMARY USE: Swimming Pool, Res. Plumb. Inst). l"ev: PENTAMATION PERMIT TYPE: 1 SFPOOLDE WORK Pool demo 325 SF SCOPE Suppl. Insp. Feer Reg. OT FEE ID # POOLS 1 DEMOPRES 'I NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E_(L LIP13 slNt;it. I�it:lr't C t7c:L'n lsrrei°s. .. ,{. ii't;•'i aleck. Perrrtrt Fee,- Plumb. Permit I�ee: Elec. fermi Fee: 41ech. Insp. Other Plumb Insfr. Other Elec. Insp. Vlec'l? InspFee: Plumb. Inst). l"ev: I:lec 1-'—,t NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E_(L LIP13 FEE QTY/FEE MISC ITEMS r Plum/ a:., eclz.; L;Iec Permit Fee: $329.00 Suppl. Insp. Feer Reg. OT 0.0 hrs $0.00 I'lrimb.i�%%r. Plumb. `'.,4,kch-/'FFee Permit `CJfZst3-action 1 ax 7: IT, 4,'()rk Without .Pe mitt? .lclvanced PlanningFees: Travel %)CICZimentalion FC'('s: Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $330.50 $0.00 TOTAL FEE: 1 $330.50 Revised: 10/01/2015 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX 1408) 777-3333 - build inoncuoertino.orQ — Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS � _ � - �U�... I..APN.`07 © I BP' fcJ' 1 OWNER NAME �7/V 7 . 0. WNER ADDRESS - DESCRIP T ION OF/WORK:' - We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit_ until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- ilder" building permit that erroneously implies that the property owner is providing his or her own labor and material p rsonally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those kijuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for inarles to workers on my property. 2. I understand. building permits are not required to be signed by property owners unless they are responsible for It construction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may pr tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. fI understand Contractors are required by law to be licensed and bonded in California and to list their license nb�ers on permits and contracts. 45. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the 5al value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 46. I understand if I am considered an "employer" under state and federal law, I must register with the state and fee—ral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family r idential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for ny financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. C' svnerEuilderrorm 2010.doc revised 04/19/10 19. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal 1t9. Service, the United States Small Business Administration, the California Department of Benefit Payments, an the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or vnrnv.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that G the party legally and financially responsible for proposed construction activity at the site address listed above. y 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will atrTde by II applicable laws and requirements that govern Owner -Builders as well as employers. f12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the rmation l have provided on this form. Licenszd contractors are regulated by-laws designed to protect.the.public. If y u contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a. result of a complaint. -.Your only remedy against unlicensed Contractors may, be in civil court. It' is also important for you -to understand that if an unlicensed Contractor or employee of that individual or irm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: z)i� Lender Address: -6 Before a buildi g permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners signature. Property Owner's Signature: S=AzLt-!:� Date:I- --- -- -- --- - -------- ----------- ------------ -- ------------------------------------------------------------------------------------------ (NOTE: The following Authorization Fo ---is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): _ n u , Project Location or Address: Q isi� v Name of Authorized Agent: Address of Authorized Agent: Tel No UD I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the properly owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 CUPERTINO ulding Department OCT 15 2015 REV1E\r.j ECR CODE COMPLIANCE Reviewed By: AdOO 301:1:10 ,j LOPNIENT r;EPARTMENT CUPERTINO APPROVED his set of plar� y' ,)eafications I`aUST be kept at the }cb site d�ar!n r` It is unia,,tifut to make any changes or ajtc:r<3tions on sat ne, or to deviate �nerefroni, from the Building Official. Ll V -r t m in �:)f this pian and specif�Cations SHALL NOT . he s.a p � OCTbe held to permit or to be an approval of the violation i 62015 of any provisio - -` a `pity Ordnance or State Law. BY BY DATE c� PERMIT` 3-59 a '/- o // Dy 2012 l PLOT PLANS C E KED DATE_fn. ��,�� G PLANNING DEPT CUPERTINO