13050119CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 923 BROOKGROVE LN
CONTRACTOR: A-1 POOL REMOVEAL
PERMIT NO: 13050119
OWNER'S NAME: YENPO LIN
P O BOX 1212
DATE ISSUED: 05/15/2013
OWNER'S ONE: 4089782903
CAMPBELL, CA 95009
PHONE NO: (408)911$-2903
JOB DESCRIPTION: RESIDENTIAL COMMERCIALS
LICENSED CONTRACTOR'S DECLARATION
G' Z Li.. # (�! , t`U
DEMOXILL (E) SWIMMING POOL, HANDOUT PROVIDED.
License Class
AREA TO BE USED FOR LANDSCAPE PURPOSES ONLY.
Date S
Contracto�ffflfigwthatl
I hereby licens under theprovisions of Chapter 9
(commenith 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: $6500
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 37539026.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
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
180 DA T CALLED INSPECTION.
upon the above mentioned property forinspection 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
slued bv. Date:
granting of this permit. Additionally, the applicant understands and will compl
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
S' ture Date S � S % 3
RE-ROOFS:
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.
AV
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I. hereby affirm that 1; 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)
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
is issued.
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Munic' al Code, Chapter 9.12 and
performance of the work for which this permit
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
the Health & Safety Code, Sections 25505, 255 , an 25534.
Owner or authorized ag Date: S S
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
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
CUP RTiN4 (408) 777-3228 • FAX (408) 777-3333 • building(a5cupertino.org n
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PROJECT ADDRESS 'L 6 AG Q � c ,G A O I/ <_
APN #
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OWNER NAME y/` ov — o t
E-MAIL
STREET ADDRESS
CrIN, STATE, ZIP
FAX
CONTACT NAME A 'I-em
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EMAIL
/`
STREET ADDRESS
CITY, STATE, ZIP
FAX
OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 2�ONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME O0� /
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LICEN E NUMB D
LICENSE
BUS. LIC #
COMPANY NAME E-MAIL
FAX
STREET ADDRESSa M CITY, STATE, ZIP
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((
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME/�^
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E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK r- • `
oa I` c
USE OF ❑ SFD or Duplex ❑ Multi -Family
TYPE
MATERIAL
TYPE (CODE)
AREA (SQ. FT.) VALUATION ($)
STRUCTURE: ❑ Commercial
POOL
POOLISPA MATERIAL TYPE CODES:
SPA
V - VINYL -LINED
DEMO
G
/Y)D S
(V/
F - FIBERGLASS
G - GUNITE
TOTAL VALUATION:
P - PREFABRICATED
O
By my signature below, I certify to each of the following: I am the property owner or au
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 build* construction. rize re sentatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of ApplicanUAgent:
Date:
SUPPLE ENTAL 0 ION REQUIREDN
- .� ,y rl-1O;L, R- L - - .M
Commercial or Multi -Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required.
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SA3�'I.TARYSEW..ERDISTRICZ:
SwimPoolApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
WNW T't Ti i'i T'i CTTM A rrn-v — RTTTT .-nim iiivl4lnN
la
imADDRESS:
923 brookgrove In
DATE: 05/15/2013
REVIEWED BY: melissa
Plan Check Fee:
APN: 375 39 026
BP#:
*VALUATION: 1$6,500
*PERMIT TYPE: Demolition Permit
PLAN CHECK TYPE:
PRIMARY Swimming Pool, Res.
Plurn b. i1i tech./Elec
PENTAMATION 1SFPOOLDEM
TYPE:
USE:
Permit Fee:
PERMIT
WORK
demo/fill a swimming pool, handout provided. area to be used for landscape purposes only.
hrs
$0.00
SCOPE
Plumb.11fech./Elec
Xtech. flan Check
ifech. Permit Fee:
Othef- Alech. Insp.
Rllech. Insp. Fee:
P/nmb. Plan Check
Plumb. Permit Fee:
Other Plumb Insp.
Plumb. Insp. Fee•
Elec. Plan Check
Elec. Permit Fee:
Other Elec. Insp.Lj
Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. riammng, rumic worKS, rare, aunitury .newer �utatrtcy 04'auut
ILContact the Deat for addn'1 info.
FEE ITEMS (Fee Resolution 11.-053 E . 7f 11112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC'l-,ce
FA
Plurn b. i1i tech./Elec
Permit Fee:
$306.00
Suppl. Insp. Fee.-(E)Reg. Q OT
Q Q
hrs
$0.00
Plumb.11fech./Elec
Plumb. iMech✓Elec Permit Fee:
Construction :Tnx:
Administrative.Fee:
Work Without Permit?
Advanced Planning Dees:
i
T rati,el Documentation Fees:
Strong Motion Fee: 1BSEISMICR
$0.65
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
$307.65
u
$0.00 r o
$307.65
Revised: 04/29/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST,
JOB ADDRESS: L ry PERMIT #
9
OWNER'S NAME: !vO ;tom, PHONE # ``zia'fl 6Or` -
!/ Z C
GENERAL CONTRACTOR: — P« BUSINES&L'ICEN.SE #
Cabinets & Millwork
ADDRESS: Pp 130 1 ZI Z CITY/ZIPCODE es
.c
*Our municipal code requires all businesses working in the city to havea City . Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) 4IL1 BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A' CITY OF CUPERTINO
BUSINESS LICENSE. _
I am not using any subcontract
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
SUBCONTRACTOR
BUSINESS "NAME
R 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
Tile
Owner / Contractor Signature
Date
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DATE 13
PERMIT NO, 0 -5-
C JPERTINO
Bui 101L.4-
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MAY 15,2013 POOL-
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RE\ IEVV�D FC]IR CODE COMPLIANCE
2-16�5
,',RevI`e ed By:
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