11040220 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20699 RODRIGUES AVE CONTRACTOR:TSH'=T'e 9F4- PERMIT NO: 11040220
OWNER'S NAME: ALEX LIU DATE ISSUED:04/28/2011
NER'S PHONE: 6504920857 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT F_ PLUMB
License Class A- Lic.# 3-7 L L
MECH F RESIDENTIAL F COMMERCIAL
Contractor .1�t2,c7 (Z---- Date 4' 7
JOB DESCRIPTION: SFDWL POOL DEMO 650 SQ FT
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:$10000
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 APN Number:35910057.00 Occupancy Type:
permit is issued. f2___
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 FR 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 4-1—2&-/
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 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.
u OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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
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 Code,Sections 25505,225533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: O2i,,,1 t'2----- Date: Z�
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
,mnify and keep harmless the City of Cupertino against liabilities,judgments,
,is,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
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35910057 . 00
DATE ISSUED. . . . . . . : 04/28/2011
RECEIPT #. . . . . . . . . : BS000013319
REFERENCE ID # . . . : 11040220
SITE ADDRESS . . . . . : 20699 RODRIGUES AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . ALEX LIU
ADDRESS . . . . . . . . . . : 20699 RODRIGUES AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : PHIL BJURMAN
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 10, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 10, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 00 0 . 00
1DEMOPRE EACH 1 . 00 291 . 00 0 . 00 291 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 408 . 00 0 . 00 408 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------- ------------
CASH 408 . 00 CASH
---------------
TOTAL RECEIPT 408 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
DEMOLITION
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20699 Rodriguo Ave DATE: 04/28/2011 REVIEWED BY: RDW
APN: BP#: ((>y D Z Z U „VALUATION: $10,000
PERMIT TYPE: Demolition Permit
PRIMARY Swimming Pool, Res. PENTAMATION 1SFPOOLDEM
USE: PERMIT TYPE:
WORD Residentil pool shell removal with compacted infill. Report required.
SCOPE
FEE ID #POOLS
1DEMOPRES
F7
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS 0'ke Resolution 09-051 f;ff ,', .-10) FEE QTY/FEE MISC ITEMS
Permit Fee: $291.00
Suppl.Insp.Fee.e Reg. OT 0.0 hrs $0.00
Strong Motion Fee: 1BSEISMICR $1.00 Select an Administrative Item
1314,,Stds Commission Fee: 1BCBSC $1.00 7 1
SUBTOTALS: $293.00 $0.00 TOTAL FEE: $293.00
Revised: 04/01/2011
FENCE
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COMMUNITY DqVELOPMENT DEPARTMENT Z
WOUILLANU LAVICAUN- j W
APPROVED
This set of plans and specifications MUST be kepl at the
job site during construction. It is unlawful to make any
changes or alterations on same,or to deviate
therefrom,without approval from the Building Official.
The s f this plan and specifications SHA NOT
bo I 3�rmit or to be an approval of the vlol tion
Of a+�EJW a of a y City Ordinance or State w.
BY
DATE 4./
PERMIT NO.
20699
R❑DRIGUES 0 S 10
AVE,
CUPERTIN❑
FEET
Building Department
City Of Cupertino
Lal 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: '2067-7 2 c/ i ✓t, A•/e� PERMIT# () 6
OWNER'S NAME: e ;,y PHONE# (Vvg YY -6 f
GENERAL CONTRACTOR: Qy, ( &.-,r BUSINESS LICENSE# ?4'2-5-0
ADDRESS: y-} -% k,,, Avg CITY/ZIPCODE: 5w,,A Jb�3c- CA, S zs—
*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 #
Cabinets & Millwork
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
71 Tile
'a,
Owner/Contractor Signature Date
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
GUPERTINO (408)777-3228• FAX(408)777-3333•building(cDcupertino,org
//U OZ2D
PROJECT ADDRESS 20677 APN# 0_57W
v
OWNER NAME PHONE E-MAIL
Ale 65-0 y12-09-5-_?
STREET ADDRESS CITY, STATE,ZIP FAX
`Z C 6 `f' r:� L%1c A
CONTACT NAME A V/ r1 PHONE6YOV`J 6 Y V/ 2 I Y_ E-MAIL
STREET ADDRESS J7 CITY,STATE, ZIP v FFA
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT XCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
'v� 62 O
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIPPHONE
1 S- Hu I Ian
Ale- S .,? CA W. Z-5- 65-0-Yc 6 7 3-33
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK / /
i o O 010 -, ` C C9 tl Yiw IIIk n1l Caj C.,rC "c' f,: I f*
G44
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 / Ito
O O
G - GUNITE I
P - PREFABRICATED ItECEIVEDBY.F TOTAL VALUATION
O Oc,
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 i orr t. 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 ing smilgelon. I authepsesgAtatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant//gent: --�`f Date: Z b
SUPPLEMENTAL INFORMATION REQUIRED
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 t ❑ SANITARY SEWER DISTRICT
SwimPoolApp_201 1.doe revised 03/16/11