08120040 CITY OF CUPERTINO 'ss
BUILDING DIVISION PERMIT CONTRAC,TUI�2.tN�`f?RMA.TI0N"�k.,
BUILDING ADDRESS: PERMIT NO.
5941 BOLLINGER RD TBD — TO BE T)FTERMINED nPigno4n
OWNER'S NAME: PERMIT ISSUE DATE
AORt2 e 8 8 CONTROL NO.
PHONE:
40:HffECTIENGINEER: BUILDING PERMIT INFO
BLDG EfECT PLUMB MECH
0 0 0 0
000 LICENSED CONTRACIOB'S DECLARATION Job Description
V I bunchy sRnm that I am licmmd.oder luo jedons of Chapter 9(commencing
With Section 70110)of Division 3 of the Business and Profmions Code.aha my license is
%+ N infull fame ameffect. RE—SURFAC EXSTNG POOL, 85SQ
piwjZ License Clasn Lic.w
n F• Damy�/sy' Contrm:mr
QQ / ARCHTIECTS DECLA ATI N
3 a U 1 umcrstanJ my plaru shill W nand u public rtcoNs
a G� Licensed Rufessional
c 5 OWNER-BUIUER DECLARATION
g2 1 hereby aRnm Nal I am aempt from Be Cantr n mre License Law for the
N O following ramon.(secel 7031.5,Business and Professions Code:Any city or county
'g m_� which requiresa permit to construct eltee impmw.demolish.or repair any structure
?iy prior In he hmance.also me,moce the applicant for such permit to file a signed statement
p oBut,heislicensed pursuant odue provisionsofthe ConecmhLiccvcfew(Chapter 9 Sq.Ft.Floor Area Valuation
y (commencing wish Section 7000)of Division 3 of the Business and Prafeulone Code)or 8853
i $ that he u exempt shcmfiom and the been for me alleged eaemptim.Any violation of
Section 7031.5 by any applicant for a permit subjttu she applicant m a civil penalty of APN Number Occupancy Type
Mt mom than Inm hundred dollars(3500). 37535022 . 00 .
I,ee owe of the property,or my wply a,with wages u nosh mlc compemdon,
will do mework.and deastmnum Is not intanded erdtfered forsale(Sec.7044,Busies
and Profeeuons Cads:The Conimctors License Taw don act apply he an own¢of Required Inspections
property who builds orimpmvn Nemo..and who doessuch work himselfor th augh his
own employes,provided them such impmwmens am not intend¢aro@ted forsale-If.
hmm,.the building or improvement Banks within one year of completion.the mmea-
builder will haw the burden of proving that he did not build or improv for purpose of
rile.).
❑1,se owner of Ne property.am rxcluuwly contracting with Becomes comomfou m
construct the project(Sec.7W.Bounty and Profeeeims Cede:)The Consumes Lf-
sem law does not apply to an owner of property who Wild,or improves themun,and,
who contracts for such projects with a contomfor(s)liecmd pursuant to the Contractors
License law.
❑I son exempt under Sao. .B B P C for We reawn
Owned Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of she fallowing dmdamtiortu
1 ham am wBl maintain aCenifmum of Co..(an self-ieeum for Worker,cmaper,
"on,u provided An by Suction 3700 of the Labor Code.for Be.peA erne nt of the
Y for which this permit is issued.
I haw and will maintain WmIxes Compensation I...as recleaned by Smjun
37W of Jte labor Code,for the performance of the work for which this permit is issued.
My Wm ,Comperumm Imo.carie and Policy number am:
Canner.
Y/?/A!I fAgOePolicyNo.:
R TEPf10NFROMWYORKSERGS'G9CL
COMPENSATION INSURANCE
(Dissection used not W cmplemd if Ne permit Is forons hundred dollen(SIM)
ort .)
1 c"^+fv,that in me performance of to week for which this permit n issued.)shall act
employ any pcome in any Insurer an as to become subject to the Workeri Competuation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you mould
become subject m to Workers Cesnpemdon pmvsions of Ne IaWr Cma.you mum
Z forthwith comply wish such provisions or this permit shall W deemed rovaked.
zO CONSTRUCTION LENDING AGENCY
[—i - 1 annual,affirm Nat chert is.consumed..lending ageocy for tha rod...of
r1 > the work far which this permit is issued(Sec.30il,Civ.C.)
{L7 Q Lenders Name -
z Lenders Addrtm
C)Q I certify that T haw mad this application and sum the the aWw information is
U, H correct.I agree to comply with all city and county mairmom and sum Ins mlaung to
0U Wilding commutation,and hereby authorize representatives of this city to enter upon the -
alOwe-mentioned property for inspection purposes
E (We)agree Io van,indemnify and Imcp homeless:the City of Cupertino against
rj) Iiabilitics.judgments,costa and expeame which may In any way accrue against send City
V z
in edmM
egnce of the granting of this Permit.
APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date ,-
SOUR EGULATIONS. j
Re-roofs
amre o,A t otncmr 'DOW -
f.� HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appikam or future Wilding occupsmsmm or handle havudom material
as defined by the Cupertino Mm!tW Code,Chapter 9.13.and the Health and Safety
Code.Section 25532(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Yea ON.
Will the applicant or future Wilding occupant m equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hverdnus air canuminanu m Jc d by the Bay Area Air Quality Management all new materials for inspection.
it los
❑Yes u
I have mad the 1%uumWs materials requirommesumerchapterfi.95 of the Califon
m e Health k SafmyCede,section,25505,25533 and 25534.1 unce mnd thmif the Wilding
dons Bat emmody ham.moa n.mar it s my mrpnmihBity he Mary Ne up.'.1 the
room no me which muss be met prior m' coo a Cenifmam of Occopmmy.
Signature of Applicant Date
All roof coverings to be Class'%}"or better
5VIIE, rSAn.d agent Dim'
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
• COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37535022 . 00
DATE ISSUED. . . . . . . : 12/04/2008
RECEIPT # . . . . . . . . . : BS000006748
REFERENCE ID # . . . : 08120040
SITE ADDRESS . . . . . : 5941 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PERVEZ MOHTA
ADDRESS . . . . . . . . . . : 5941 BOLLINGER RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3536
RECEIVED FROM . . . . : FIBERGLASS POOL
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
-- ---------- ------ ---------- ---------- --- ---
1BSEISMICR VALUATION 8, 853 . 00 0 . 90 0 . 00 0 . 90 0 . 00
1BUSLIC FLAT RATE 1. 00 114 . 00 0 . 00 114 . 00 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 .79 0 . 00
TOTAL PERMIT 237 .27 0 . 00 237 . 27 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 237 .27 MC
---------------
TOTAL RECEIPT 237 .27
•
Community Development
v 10300 Torre Avenue
Cupertino CA 95014
,r W.
J _
' Telephone(408) 777-3228
CITY OF Fax(408)777-3333
CUPERTINO
Building De artment
JOB ADDRESS: PERMIT # DSI o2 Cw /
/ / n 7
OWNER'S NAME: e`t a ry PHONE # Yd 77'
GENERAL CONTRACTOR: —/ FAX # - _oe
I am not using any subcontractors: / -- i t / y/a &--
SignatureDate
Please check applicable subcontractors and complete the following ' ormation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
• Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
]Tile
Owner/Contractor Signature Oate
+ CITY OF CUPERTINO Okl d oo vu
4' h SWIMMING POOL/SPA
C1 OF
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
o A-
Mailing Address (if diffe ent from building address):
/
Owner's Name: Phone #:
07.qlil4e, ?�v a N- O - 7-
777 9, 25
Contractor: Phone#: Contractor License #:
�/ os/ Fax #:Zg5--2 1C-d7qi 617
Contact: Phone#: Cupertino Business License #:
<e ✓ Fax #: -O
Residential Commercial
Job Description:
Valuation (cost of projec : Square Footage:
�a
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set& the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1POOLCOMM Commercial Pool B CBSP
IBSEISMICO Seismic Commercial B
1POOLVINYL Vinyl-lined (up to B RBSP
800 sf)
1POOLFIBER Fiberglass B
I POOLGUNITE Gunite (up to 800 sf) B
r'
CITY OF CUPERTINO
Se
SWIMMING POOL/SPA
CUPEkTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group Permit Type
1 SPAPREFAB Spa or Hot Tub (Pre- B
fabricated) 4 �_
1SAUNA Steam Sauna B
r 1BSEISMICR Seismic Residential B
1PLMBLNCK Plumbing Plan Check P
1PPERMITFEE ' 'Plumbing Permit P
J/ 1MPERMITFEE Mechanical Permit M
/ IEPERMITFEE Electric Permit E
1TRAVD0C Travel & Documentation
' 1BUSLIC . Business License B
Revised 6/16/08