12030157 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21735 COLLINGSWORTH ST CONTRACTOR:A TO Z POOL-AND SPA PERMIT NO: 12030157
REPAIR
OWNER'S NAIVE: ITOH TATSUO AND SEIKO 10289 MENHART LN DATE ISSUED:03/30/2012
OWNER'S PIIONE: 4087251334 CUPERTINO,CA 95014 PHONE NO:(408)374-6268
❑ LICENSED CONTRACTOR'S DECLARATION JOBDESCRIPTION: RESIDENTIALU COMMERCIAL
License Class C S 3 LLic.4 n2w, SFDW L POOL DEMO 400 SQ FT
Contractor
I hereby affirm that 1 am licensed under the 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.
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 whichthis permit is issued. Sq.FI Floor Area: Valuation:$6500
1 have mid will maintain Workers Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
APN Number:35617067.00 Occupancy Type:
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
upon the above mentioned property far inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by: /9n:� 1
�Sir✓ Date: 3'J��` •i
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature /�`""�� //� �--- Date 3( `�'— All roofs shall be inspected prior to any roofing material beiig installed, If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that 1 em exempt from the Contractor's License Law for one of Signature of Applicant: Date-
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 properly,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safely Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth&Safety Code,Section 25532(a)should 1 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 air contaminants as defined by the Bay Area Air Quality Management District l
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505.25533 an 25534.
Section 3700 of the Labor Code,for Oce performance of the work for which this
Owner or authorized agent:
permit is issued- Dete:
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
became 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,Cir 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
and keep harmless the City of Cupertino against l iabil ities.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
City of c u pertln AfiTMENT
110 C EPAZ
APPROVED
This set of plans and specifications MUST be kept at the
job site during construction. It is unlawful to make any
PF,C Ei 1V D changes or alterations on same,or to deviate
therefrom,without approval from the Building Official.
MAR 3 2012 The stamping of this plan and specifications SHALL NOT
be held to permit or to be an approval of the violation
BY: of any provisions of any City Ordinance or State Law.
BY �E�/
DATE 3 30 • i o�
30
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SCALE 1 : 264
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PEKE COPY
http://gissvr/cupertinointranetthome/mapFile:aspx Friday, March 30, 2012 11:31 AM
CITY, OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35617067. 00
DATE ISSUED. . . . .. . : 03/30/2012
RECEIPT #. . . . . . . . . : BS000016409
REFERENCE ID # . . . : 12030157
SITE ADDRESS . . . . . : 21735 COLLINGSWORTH ST
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACTAREA . . . . . . .
OWNER . . . . . . . . . . . . : ITOH TATSUO AND SEIKO
ADDRESS . . . . . . . . . . : 21735 COLLINSWORTH AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4708
RECEIVED FROM . . . . :. THE POOL GUYS
CONTRACTOR. . . . . . . . : MICHAEL L. LINZELL LIC # 28953
COMPANY . . . . . . . . . . : A TO Z POOL AND SPA REPAIR
ADDRESS 10289 MENHART LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . : (408) 374-6268
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
---------- ------------- ---------- ------ ---------- ---------- ----------
1BCBSC VALUATION 6, 500. 00 1. 00 0. 00 '1. 00 0. 00
1BSEISMICR VALUATION 6, 500.00 0.65 0. 00 0.65 0 .00
1BUSLIC FLAT RATE 1.00 119. 00 0. 00 119. 00 0. 00
1DEMOPRE EACH 1.00 300. 00 0. 00 300. 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 420.65 0. 00 420 .65 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 420.65 11167
---------------
TOTAL RECEIPT 420.65
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
SWIMMING POOL / SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPER 0 (408)777-228• FAX(408)777-3333•buildingiftupertino.om
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PROrECT ADDRESS .Z 36
APN tl 5 LP O Co
OWNER NAME / 6 PHONE /9 SLI EMAIL
STREET ADDRESS .'�J S I� O.G Cm' sTA�zip
C I/ FAX
CONrACT NAME 7 PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
OWNER ❑ OWNER-BUILDER ❑ owmut AGENT ❑ CONiRACrOR 13 CONTRACTOR AGENT ❑ ARCHRECT ❑ENGWEER ❑ DEVELOPER ❑ TENANT
CONTRACI'ORNAME /�- LICENSE NU . LICENSE TYPE r BUS.LICtl
COMPANY NAME .` / E-MAB. ?�A^1I" Z J! FAx
sraEETADDaFss CITY,STw'fE,ZIP PHO
ARCHITECUENGINEER NAME - LICENSE NUMBER BUS.LICtl
COMPANY NAME E-MAB. FAX
STREET ADDRESS CFTY,STAT$ZIP PHONE -
DESCRIPTION OF WORK
USE OF ❑ SFD or Duplex . Multi-F=' ily TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION (S)
STBUCTTIRE: ❑ Commercial POOL
N liUa
POOTISPA MATERIAL TYPE CODES: SPA
V - VINYL-LWED
F - FIBERGLASS DEMO
G - GUNTB
P - PREFABRICATED a CELY®BV--F- -'�-'^' `- '� -c TOTAL VAe ON
By my signature below,l certify to each of the following: I am the property owner or authorized 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 accurme. 1 agree to comply with all applicable local
ordinances and state laws relating to buil nsw I `resentativ f Cupertino to enter the above-identified prope for inspection purposes.
Signature of Applicant(Agent Date: np
SUPPLEMENTAL'INFORMATIONREQUUtED s; p ❑Ce ''N—y'` h- r,
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SwimpooL4pp_2011.doc revised 03/16/11