D-2016-0363C
E91
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2016-0363
19766 VICKSBURG DR CUPERTINO, CA 95014-3322 (369 10 008)
(S & B
CONSTRUCTION)
SUNNYVALE, CA 94087
OWNER'S NAME: GUPTA MAYANK AND PARUL
DATE ISSUED: 01/21/2016
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. # 0 Sq 55 -
Contractor ( S & B CONSTRUCTION ) Date
—BLDG —ELECT _ PLUMB
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
Demolish existing in -ground swimming pool (600 sq ft)
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.
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
Sq. Ft Floor Area:
Valuation: $5000.00
this permit is issued.
APPLICANT CERTIFICATION
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
369 10 008
369
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 indemnify and keep
harmless the City of Cupertino against liabilities, judgments, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT. ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST CALLED INSPECTION.
Code, Section 9.18.
Signature ----Date � �
Issued by:
Date: ./ l
OWNER -BUILDER DECLARATION
RE ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without fust obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (See.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three 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
. HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner ora tHorized agent:
Pate:Lq
APPLICANT CERTIFICATION
I CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
Professional
Signature Date
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 • building @,,cupertino.org
PROJECT ADDRESSN ` �f `C ��_s n 6 'T}�
APN #
41
PHONE �j1S 1�— i� (J I G / (a
(ZIP `— tl (O
E-MAIL
STREET ADDRESS - /
CITY, STATE,
FAX
CONTACT NAME
PHONE
I
E-MAIL
T
1fU
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT El�CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
✓/ /
LICENSE TYPE Z
F�
BUS. LIC #
V'\CC LiL
_
COMPANYNAME (/_j p _
E-MAIL
FAX
STREET ADDRESS
4 2 L �ti{ L, Com
CITY, STATE, ZIP
- �,� ll�
PHONE / �� /��d%
o�-`
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORKcJOL
SFD or Duplex ❑ Multi -Family
TYPE
MATERIAL TYPE (CODE)
AREA (SQ. FT.)
VALUATION ($)
USE OF
POOL
%
(J
6UG
STRUCTURE: E] Commercial
POOLSPA MATERIAL TYPE CODES:
SPA
V - VINYL -LINED
F - FIBERGLASS
DEMO
G - GUNITE
P - PREFABRICATED
w
REGEIVEDBI'ri
Ives
TOTAL VALUATION:
By my signature below, I certify to each of the following: I am the property owner or authorized 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 burepresentatives of Cupertino to enter the above -identified property for inspection purposes.
99 Date:
Signature of Applicant/Agent:
SUPPLEMENTAL AT D y r EN
s -SK.
4JP'Y 1
? PLANCFiECKTYPE'",. R 7 ,>, ? ROUTII�GSLII'
Commercial or Multi -Family Buildings with Public Swimming Pools:; si
Department of Environmental Health approval required. oVERTxEjcollNiER .BUIIDINGDEPT
R'���y
❑ E7�RES59PiANNINGDEPTi'
t ❑ EUBLIG WORKS DEPT a t
L`ARGE fi. �.�5 '� � �ENVIIt�NMEN�'AIs HEALTH,
w 4" �� ��
SwhnPooUpp_2011.doc revised 03/16/11
3 . c.
CITY OF CUPERTINO
W -51-N FF.F FSTIMATOR - BUILDING DIVISION
,
ADDRESS: 19766 Vicksburg Dr
im
FDATE: 01/21/20.16
REVIEWED BY: Sean
APN:
BP#:
I
*VALUATION: 1$5,000
1*PERMIT TYPE: Demolition Permit
-111\1
1'1:;..:.:::1:/1.:;L
PRIMARY Swimming Pool, Res.
USE:
I
PENTAMATION M
� PERMIT TYPE: 1SFP00LDE
WORK
Demolish existing in -ground swimminq pool (600 sq ft)
SCOPE
Permit Fee:
VOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). Thesefees are based on the preliminary information available and are only an estimate Contact the Dept for adan't in)o.
FEE ITEMS (Fee .Resolution .1.1-053.Lf. 711113)
FEE
QTY/FEE
MISC ITEMS
Man Check.f`ftl:
Permit Fee:
$329.00
Suppl. Insp. Fee:(j) Reg. 0 OT
0.0
hrs
$0.00
Fee:
iavel
Strong Motion Fee: IBSEISMICR
$0.65
Select an Administrative Item
Bld,, Stds ommission;Fee: IBCBSC
$1.00
SUBTOTALS,
$330.65
$0.001 TOTAL FEE:
$330.65
Revised: 01/01/2016
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