12120004 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10551 N BLANEY AVE CONTRACTOR:RICHIE BOBCAT& PERMIT NO: 12120004
HAULING
OWNER'S NAME: FRIESON DOUGLAS L ET AL 396 PATCH AVE DATE ISSUED: 12/03/2012
OWNER'S PHONE: 4084202773 SAN JOSE,CA 95128 PHONE NO:(408)529-2531
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class G_e i —n 64 Lic.# 4 19 4 t 0 SFDW L POOL DEMO 500 SQ FT
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.
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:$2500
1 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 APN Number:31634028.00 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 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 DAYS FROM 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 I `
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.
RE-ROOFS:
Signature 2 •�-1 Date t'+..—'r—t z 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 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
1,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(Seo.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 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 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: V -1+ Date:
permit is issued.
1 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 of 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 1 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
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 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 DUS P
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255O
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinge-cuoertino.orG
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PROJECT ADDRESS APN# 2z I O�,j
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OWNER NAME I PHONE E-MAIL
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CONTACT NAME PHONE E-MAE.
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STREET ADDRESS CITY,STATE, ZIP FAX
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❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAOENr ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LICA
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STREETADDRESS CTI`Y fATE,ZIP PHONE
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ARCHTTEMENGINEERNAME LICENSE NUMBER BUS.LIC k
COMPANYNANM E-MATE FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION(S)
STRUCTURE: ❑ Commercial POOL
fen frXer oc� nZ$du, oc7
POOLISPA MATERIAL TYPE CODES: SPA
V - VWYI,-LINED
F - FIBERGLASS DEMO
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P - PREFABRICATED TOT ALUA ON:
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 building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicanUAgent: Q. _}-da= Date: t z-q-♦L
SUPPLEMENTAL INFORMATION REQUIRED -� - T '- -
Commercial or Multi-Family _ =
-Family Buildings with Public Swimming Pools: - -
Department of Environmental Health approval required.
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DEVELOPMEN -DEPARTMENT _
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APPR cD
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