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06100187 CITY OF CUPERTINO BUILDING'DIVISION PERMIT G INT T�iR IN ORM.�TI4IN BUILDING ADDRESS: ADAMS POOL SOLUTIONS PERMIT NO. 06100187 22009 OAKDELL PL PERMIT ISSUE DATE OWNER'S NAME: GRACE KIM 3675 OLD SANTA RITA RD. 10/26/2006 INE: SANITARY NO. CONTROL NO. (925) 928-3100 ABUILDING PERMIT INFO RCHITECT/ENGINEER: BLDG ELECT PLUMB MECH i O p LICENSED CONTRACTOR'S DECLARATION Job Description m I hereby affirm that I am licensed under provisions of Chapter 9(commencing 2 Z UJ with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is "e 0- in full force and effect. NEW WATER CIRCULATION PLUMBING FOR POOL, ;�2z DaenscClass Contractor ADD NEW POOL LIGHT ASSOCIATED WIRING �t,,,p Datc Contractor ARCHITECTS DECLARATION .a U I understand my plans shall be used as public records UO l- Licensed Professional y OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the in Oa following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuati 9 0 0 _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area ut (commencing with Section 7000)of Division 3 of the Business and Professions Code)or L that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of pp Number Occupancy Type not more than five hundred dollars(SSW). 3 2 63 9 0 0 5 0 0 ❑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 Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). (il,as owner of the property am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- cense Caw does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. C]I am exempt under Sec. j B&P C for this reason Owner /��� Date 1012- b 4 WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: Q 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- sation,as provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Polity number are: Carrier. Policy No.: AT CERTIFICE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner to be om subject to the Workcrs'Compensation Laws of California.Date �� Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J Q forthwith comply with such provisions or this permit shall be deemed revoked. z. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of �+ the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name Lender's Address U 0 1 certify that I have read this application and state that the above information is LI,r'" correct.I agree to comply with all city and county ordinances and state laws relating to CU building construction,and hereby authorise representatives of this city to enter upon the Uabove-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against C/I liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. Dace APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: t&W / SOURCE REGULATIONS. /0/"/°,L Re-roofs Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? --!! All roofs shall be inspected prior to any roofing material being installed. ❑Yes ono Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes �Nu 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must bermel prior to issuance of a certificate of Occupancy. Signature Of Applicant Date All roof coverings to be Class"B"or better Owner or authorized agent Date b k,, Community Development 10300 Torre Avenue �'" Cupertino CA 95014 Telephone(408)777-3228 CIMOF Fax(408)777-3333 "UPEkTINO Building Department JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE # 406-'11& -S4$9 GENERAL CONTRACTOR: FAX # 406 -- 3 L�, - (4 y I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 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 C �o ZL o� Owner/Contractor Signature Date CITY OF CUPERTINO 3m 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN 32639005 . 00 DATE ISSUED. . . . . . . : 10/26/2006 RECEIPT # . . . . . . . . . : 36574 REFERENCE ID # . . . : 06100187 SITE ADDRESS . . . . . : 22009 OAKDELL PL SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER GRACE KIM ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : GRACE KIM CONTRACTOR EARL ADAMS LIC # 25237 COMPANY ADAMS POOL SOLUTIONS ADDRESS 3675 OLD SANTA RITA RD. CITY/STATE/ZIP . . . : PLEASANTON, CA 94588 TELEPHONE (925) 928-3100 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - - - - - - - - - - -- - - --- - - - --- - -- - ------ ----- ----- ------- - -- --- ------- -- --- --- -- BPERMFEE VALUATION 3 , 900 . 00 104 . 76 0 . 00 104 . 76 0 . 00 BSEISMICRE VALUATION 3 , 900 . 00 0 . 50 0 . 00 0 . 50 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 ---- ----- - ------ -- -- ---------- -- ---- -- -- TOTAL PERMIT 182 . 00 0 . 00 182 . 00 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER - - - - - - - - - - ---- - - - - - ----- - - - -- - - ----- ------- --- - OTHER 182 . 00 MASTERCARD TOTAL RECEIPT 182 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING :u CITY OF CUPERTINO C(01 col a I CITY Of PERMIT APPLICATION FORM CUPEkTINO APN# Date: 3w �- WC) Building Address: Mailing Address (if different from building address): 2zoo Oa eil 1 Com, Owner's Name: Phone#: C`V-c,ce 6/40 3(,C - Iu4 Contractor: License AJ foo Contact: Phone: 4 U6--i 1 b_5q W v1 Cupertino Business License#: Fax: 4o g - i 2-157- Building Permit Info: Bldg ❑ Elect L Plumb EJ/ Mech ❑ Job Description: New Wa-k- Urc-lo%h..,:_ rl"m6► - r.,I, adA new PC") iZsy►�-y Residential ❑ Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project:. 3 1 qo p Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax-Resi/Mobile BUILDING BELEC 1000 Elec 600V<= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3