10100124 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21745 COLLINGSWORTH ST CONTRACTOR:A TO Z POOL AND SPA PERMIT NO: 10100124
REPAIR
"NWNER'S NAME: GEORGE YANO 10289 MENHART LN DATE ISSUED: 10/15/2010
.JNER'S PHONE: 4082531862 CUPERTINO,CA 95014 PHONE NO:(408)374-6268
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Li,.#`�2 POOL DEMO 350 SQ FT
Contractor Date
I hereby affirm that I 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 which this permit is issued. Sq.Ft Floor Area: Valuation:$6000
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 this APN Number:35617068.00 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 entl-r 180 DAYS FROM LAST CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We)agree to savt
indemnify and keep harmless the City of Cupertino against liabilities,judgment i, /
costs,and expenses which may accrue against said City in consequence of the Issued by: Date:
granting of this permit. Additionally,the applicant understands and will compl',
with all non-point source regulations per the Cupertino Municipal Code,Sectio i
9.18.
c RE-ROOFS:
,,i nature Date��f5 0 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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 compens ttion,
will do the work,and the structure is not intended or offered for sale(Sec.7044
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractor s to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I 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 I
performance of the work for which this 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 b� the Health&Safety Code,Sections 25505,25533,and 25534.
c
Section 3700 of the Labor Code,for the performance of the work for which this *Svner or authorized agent: Date:1/2) s o
permit is issued.
I certify that in the performance of the work for which this permit is issued,I s call
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemptio t,1
become subject to the Worker's Compensation provisions of the Labor Code, 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,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information i;
correct.I agree to comply with all city and county ordinances and state laws rt lating
to building construction,and hereby authorize representatives of this city to er ter
-nn the above mentioned property for inspection purposes.(We)agree to saN a ARCHITECT'S DECLARATION
mnify and keep harmless the City of Cupertino against liabilities,judgme its,
.;its,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 compy
with all non-point source regulations per the Cupertino Municipal Code,Secti on Licensed Professional
9.18.
Signature Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR/ iUBCONTRACTOR LIST
JOB ADDRESS: j PERMIT# 0
OWNER'S NAME: b PHONE# l' 'z
GENERAL CONTRACTOR: --,BUSINESS LICENSE #
ADDRESS: CITY/ZIPCODE: T r v
*Our municipal code requires all businesses working; in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: ly,�����
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
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY CF CUPERTINO
3 ITEMS OF 3 PERNIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Elk: Lot:
APN = 5617068 . 00
DATE ISSUED. . . . . . . : 10/15/2010
RECEIPT #. . . . . . . . . E;S000011763
REFERENCE ID # 7.0100124
SITE ADDRESS . . . . . : 21745 COLLINGSWORTH ST
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER GEORGE YANO
ADDRESS 21745 COLLINSWORTH ST
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4708
RECEIVED FROM 14IKE LINZELL
CONTRACTOR 14ICHAEL L. LINZELL LIC # 28953
COMPANY . . . . . . . . . . : k TO Z POOL AND SPA REPAIR
ADDRESS L0289 MENHART LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE (408) 374-6268
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ----------
1BCBSC VALUATION 6, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 6, 000 . 00 0 . 60 0 .00 0 . 60 0 . 00
1DEMOPRE EACH 1 . 00 291. 00 0 . 00 291 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 292 . 60 0 . 00 292 . 60 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ----------------
CASH 292 . 60 CASH
---------------
TOTAL RECEIPT 292 . 60
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ---
704 DEMO
DEMOLITION
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: J$6,000
*PERMIT TYPE: Demolition Permit
PRIMARYPENTAMATION 1 SFPOOLDEM
USE: Swimming Pool, Res. PERMIT TYPE:
WORK
SCOPE
FEE ID #POOLS
1 DEMOPRES
t'!tc 1�':•r;Z( i+<c. j'(«.r c r'_'C�i
NOTE: These fees are based on the prelintinary in ormation available and are only an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resohdion 09-OSI Eff. T'1/10) FEE QTY/FEE MISC ITEMS
---T7=
sillo tl. PC/"(V
Plafml.::t1�'ch `I_e'Ic'u phill Chcck:
Permit Fee: $?91.00
Suppl. Insp. Feer Reg. 0 OT 0.0 hrs $0.00
1'lit III h. 4cch.%1'Ic'c 1'eemit 1-'cc.'
C.`uttslrrrc�ti��n
Tax
t��COtd5{tCttt 1tC'1'tchL `e'z':
14"Orh 11 ithout
l7�irF77'llttS.; 1`t`r:',g:
I7"i{}C'i OOc'jt1J7.'wLllttili 1'e,'.c'.1': �
Strong,Motion Fee: IBSEISMICR $0.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 5 292.60 $0.00 . TOTAL FEE: $292.60
Revised: 9/29/2010
CITY OF CUPERTINO
DEMO
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
LP O W 16
Building Address: u/0/ -ti.
Mailing Address (if different from buil mg ac dress):
Owner's Name: Phone:
Contractor: `� �/ {E - .� Phone :,
hone : -l�� •'
`�- lL�2 "
Fax:
Contractor License #:
Cupertino Business License #:
Contact: Phone: l
Fax:
Residential [ Sq Footage Commercial ❑ Sq Footage
Job Description:
Valuation:
Project Size: Express Standar Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo•Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DEMV
1BCBSC Cal Bldg Standards B ALL PERMIT
Comnassion Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 01/07/09