15100044 CITY OF CUPERTINO BUILDING PERMIT
III I LDING ADDRESS: 10656 AMULET PL CONTRACTOR:ENCINO CONSTRUCTION PERMIT NO: 15100044
INC
OWNER'S NAME: GHOSH INDRANATH AND PARAMA 423 MENKER AVE DATE ISSUED: 10/06/2015
OWNER'S PHONE: 4088139207 SAN JOSE,CA 95128 PHONE NO:(408)656-4363
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
DEMO/FILL(E)SWIMMING POOL&FILL FOR LANDSCAPE
j /
License Class—1PURPOSES ONLYam— Lic.# 7 Lz,L
Contractor A)v!I r /-Date /10
I hereby affirm that I am licensed under the provisions of Chapter 9
I(4 mmencing with Section 7000)of Division 3 of the Business&Professions
t mle and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: Valuation:$5000
t 1 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 %I'N N u in he :32643059.00 Occupancy Type:
p rformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as provided for by
ction 3700 of the Labor Code,for the performance of the work for which this
permit is issued., PERMIT EXPIRES IF WORK IS NOT STARTED
/ A LICANT CERTIFICATION WITHIN 180 DAYS-OF-PERMIT ISSUANCE OR
I certify that I hail read this application and state that the above information is D CALLED INSPECTION.
correct.I agree to comply with all city and county ordinances and state laws relatin
to building construction,and hereby authorize representatives of this city to ent
upon the above mentioned property for inspection 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
granting of this pe
rmit. iti ally,the applicant understands and will comply with
all non-point source re ati s er the Cupertino Municipal Code,Section 9.18. RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
Signature Date —6 /S� installed without first obtaining an inspection,1 agree to remove all new materials for
�4" inspection.
❑ 1ZOWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
t. 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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the
2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should 1 store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should 1 use equipment or devices which emit hazardous air
r. 1 have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain co pliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued.
I lealth&S ety Code,Sections 25505,25533,and 25534.
2. I have and will maintain Worker's Compensation Insurance,as provided for by Own authoriz d n.: / /
Section 3700 of the Labor Code,for the performance of the work for which thisDater
permit is issued.
3. 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that 1 have read this application and state that the above information is I understand my plans shall be used as public records.
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 Licensed Professional
upon the above mentioned property for inspection 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
granting of this permit.Additionally,the applicant understands and will comply with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
signature Date
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX (408)777-3333•building aQcugertino.org/��
CUPERTINO
PROJECT ADD S APN 11 rJ _ I O
/D 9
OWNER NAME PHONEL' E-MAIL
p o
STREET ADDRESS CITY, STATE,ZIP FAX
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CONTACT NE 1 PHO .6 G� E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGLNEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �l LICENSE NUMBER LICENSE TYPE BUS.LIC N
l�(
COMPANY NAME E-MAIL FAX
U
STREET ADDRESS Cw ) CITY,STATE,ZIP 5 PHONE 7
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC a
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
df ,00L v i Al
USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT) VALUATION (S)
STRUCTURE: ❑ Commercial P00
POOUSPA MATERIAL TYPE CODES: SPA
V - VrNYL-LINED
F - FIBERGLASS DEMO G
G - GUNITE
P - PREFABRICATED RECEIVE�BY - TOTAL VALUATION. 4,
By my signature below,I certify to each of the following: I am the property own r authorized agent to act on the property owner*behalf I have ad this
application and the information I have prov' ed is correct. I have read th escription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil g construction. I authorize a esentatives of Cupertino to enter the above-identifieed property for inspection purposes.
Si_'nature of Applicant/Agent 4 ___ Date
SUPPLEMEN L INFORMATION REQ D oFFICEuseorvLY
PLAN CHECK I-}'pg - ROUTING SLIP
_Commercial or Multi-Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required. El OVER-Tnl `cll`trFz ElkNNIN DEPT
❑ ExrRF,ss EJPLI.�N�INc nEPr
❑ S"I':\\DaRU ❑ I'LPLIC\YORKS DEPT
❑ LARGE .--- I IRONMENTAL HEALTH
❑ MAJOR U SANITARY SEWER DISTRICT.
SwimPoolApp_2011.doe revised 03116/11
CITY OF CUPERTINO D
FEE ESTIMATOR - BUILDING DIVISION
kAPN:
DDRESS: 10656 AMULET PL DATE: 10/06/2015 REVIEWED BY: MELISSA
326 43 059 BP#: 'VALUATION: 1$5,000
PERMIT TYPE: Demolition Permit
PRIMARY Swimming Pool, Res. PENTAMATION 1SFPOOLDEM
USE: PERMIT TYPE:
WORK DEMO/FILL E SWIMMING POOL & FILL FOR LANDSCAPE PURPOSES ONLY
SCOPE
FEE ID # POOLS
1DEMOPRES
Li
LJ L E:1 -L
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the preliminar3 information available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 11-053 lfJ 1 13l FEE QTY/FEE MISC ITEMS
Permit Fee: $329.00
Suppl. Insp. Fee a Reg. Q OTTO-01hrs $0.00
Pl11/71h. Ifcrch.,F/cc
Plumb-1fec•h. Eke Permit Fc-
Cnttstructior7 Tux:
F-1
Administrative Fc,
ll'nrk !I`ith�nit Pv•nlit?
:=ldvuncc�cl l'lunni�it; F ,.
Trcncl l)ocuiucrtrha/inn i , • �
Strong Motion Fee: IBSEISMICR $0.65 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $330.65 $0.00 TOTAL FEE: F $330.65
Revised: 10/01/2015
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