D-2016-0364CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: D-2016-0364
8077 HYANNISPORT DR CUPF.RTINO,CA 95014-4011 (356 11 010)
TOM NGUYEN
CONSTRUCI'lON
200 FORD RD SP 175
OWNEIPSNAMD: RICKMAN WILFORD MTRUS'FFE&Is`fAL
DATE ISSUED:02/01/2016
OWNER'S PHONE: 408-761-8822
PHONE NO: 408-693-7659
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class B Lie. tk972671
BLDG
Contractor TOM NGUYEN CONSTRUCTION Date 02/011201Q
— _ELECT' _PLUMB
MECII X RESIDENTIAL COMMERCIAL
[ hereby affirm that 1 aim licensed under (lie 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.
JOB DESCRIP"PION:
REMOVE/FILL (E) S WIMMINC POOL & FILL FOR LANDSCAPE
I hereby affirm under penalty of perjury one of the following two declarations:
PURPOSES ONLY
r. 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,
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
Sq. Ft Floor Area:
Valuation: $3000.00
this permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above
APN Nnnnhcr:
Occupancy Type:
information is correct, I agree to comply with all city and county
56 ll O10
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 indemnify and keep
harmless the City of Cupertino against liabilities, judgments, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST INSPECTION.
Code, Section 9.18.
Issued by: MEI,ISSANAML
Signature Date 02/01/2016
Date: 02/O]/2016
OWNER-RIJD DER DECLARATION
RE -ROOFS
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
r. 1, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
1. I, as owner of the property, can exclusively contracting with licensed
Date: 02/01/2016
contractors to construct the project (Sec,7044, Business & Professions Cade).
ALI., ROOT''' COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury Due of the following three declarations:
r. 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
HAZARDOUS MATERIALS DISCLOSURE
performance ofthe work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. 1 have and will maintain Worker's Compensation Insurance, as provided for
Callfenia Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
this permit is issued.
a. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by tine Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance wifh the Cupertino Municipal Code, Chapter 9.12 slid
Worker's Compensation laws ofCalifomia. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25.533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this pemrit shall
_
Owner or authorized agent:
be deemed revoked.
Date: 02/01/2016 �� "-`
APPLICANTCER'1'IFICATION
I certify that I have read this application and state that the above information is
CONSTRIJC'I'IO LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (INe) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lenders Address
judgments, costs, and expenses which may accrue against said City in
ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally, the applicant
I understand my plans shall be used as public records.
understands and will comply with all non -point source regulations per the
Cupertino Municipal Code, Section 9.18.
Licensed
Professional
Signature Date 02LQ112016
CUPERTINO
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 S P
(408) 777-3228 • FAX (408) 777-3333 • buildin gjd ert�rg
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PROIHCTA DRESS
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OWNER AME LI Vla..pp� �
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EMAIL
STREETADDRESS
CITY, STATE, ZIP
FAX
CONTACT NAME
E-MAIL
J
STREETADDRESS /
FAX
CITY, STATG ZIP rr
El OWNER ❑ OWNER-BUILDHR ❑ OWNER AGENT )�CONIEACI'OR CONTRACTOR AGENT ❑ ARCHD'EC'T ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME
LICE N PNU ER
LiCF,N .TYPE
BUS. LICH
YP1 Y
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COMPANYNAME
E-MAIL 00
FAX
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sTRELIT ADDRESS
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Ce STATE, ZIP
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PHONE
ARCHITHCUENGIN .ER NAME
LICHNSH NUMBER
BUS. LIC A
COMPANY NAME
E MAIL
FAX
STREET ADDRESS
CITY, SPATE, ZIP
PHONE
DRSCRIPDON OF WORK t
2
USE OF ❑ SFD of Duplex 'pp Multi -Family
✓ �
TYPE
MATHRIALTYPE(CODE)
AREA (SUET)
VALUATION(F)
POOL
S'FRUCFURE: ❑ Commercial
PO,pWSPA MATHRIALTYPE CODES:
SPA
V VINYL -LINED
F - FIBERGLASS
DEMO
G -- GUNTI'E
R 'LIVEDEY
TA ALUATIW n
1' - PREFABRICA1'ID
u
By my signature below, I certify to each ofthe following: I am lh wne r authorize g o act on the property owner's behalf I have read this
application and the information I have provided is correct. I have read the Descn ork and verify it Is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building cousmiction. t authorize representatives of Cupertino to enter the above-identihe pr/o}Ierty for inspection purposes.
Signature of Applicant/Agent. -�_ Date: .
SUPPLEMENTAL INFO ATION REQUIRED
: OFFICE
USE ONLY
PLAN CHECK I YPC..
ROUTING SLIP
Commercial or Multi -Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required.
DYER -THE COUNTER
-
❑ BUILDING DEPT
❑ EXPRESS
❑ PLANNINGDEP't'
❑ STANDARD
❑ PUBLICWORKS,DEPT
❑ LARGE
❑ ENVIRONMENTAL HEALTH
❑ MMOR-"
❑ SANITARY SEWER DIST RICE
SwimPoolApp_ 2011, doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
S: 8077 HYANNISPORT DR DATE: 0210112016
REVIEWED BY: MELISSA356 M
ias
7APN3,56-010 BP#: B-2016-0364
VALUATION: $3,000
*PERMIT TYPE: Demolition Permit
P1-1 t Uf,-XX 1)PE:
PRIMARY
Swimming Pool, Res.
PENTAMATION
1SFPOOLDE
USE:
PERMIT TYPE:
WORK
REMOVE/FILL E SWIMMING POOL & FILL FOR LANDSCAPE PURPOSES ONLY
SCOPE
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1"'fec. tn'.p. Fee.
NOTE. This estimate does not include fees Clete to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District etc ). Thace fen_c are hawed nn the nrelLninary information available and are onlv an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11,(53 A,& 711113)
FEE
QTY/FEE
MISC ITEMS
1 'Ian 1,
Sae/ Jil. C' it ire
F'Xutn8.;1,4e>cl�..='f:fec
Permit Fee:
$329.00
Suppl. Insp. Fee:Q Reg. 0 OT
0.0
1 hrs
$0.00
PI rtrrtl;.;11 rclr.; T;lec Permit ,''ce
"onsirurfion Tat-:
'Idwinofy%ffive Pec'
rf"Orz iFithow Perrr7ri'
Adwinced plrzrrnin'., Fern:
Tr(xm/T3acurfwwarwn Fee,%,
Strontr Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$330.50
$0.00 � TO`I`A AIM.
$330.50
Revised: 01/01/2016
CUPERTINO
Eiuilding Department
FEB 01 2016
fitwED FOR CODE
Reviewed By:
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