10060027 CITY OF CUPERTINO :'3UILDING PERMIT
BUILDING ADDRESS: 10520 CASTINE AVE CONTRACTOR:GARY W.& MARY PERMIT NO: 10060027
TIE TZ
NNER'S NAME: GARY W.& MARY TIETZ 101_20 CASTINE AVE DATE ISSUED:06/07/2010
OWNER'S PHONE: 4087330414 CUPERTINO,CA 95014-1311 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALE]
License Class Lic.# POOL DEMO
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:$1000
1 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:32644039.00 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 for 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: Date:V.01 V J-1 0-
with all non-point source regulations per the Cupertino Municipal Code,Section _
9.18.
RE-ROOFS:
,nature Date 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
ins lection.
OWNER-BUILDER DECLARATION
Sit nature of Applicant: Date:
I hereby affirm that 1 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 compensation,
will do the work,and the structure is not intended or offered for sale(See.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors 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 m�intain 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 mf terial. 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. wi l maintain compliance with the Cu ertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by thi Health&Safety Code,Sections05,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
permit is issued. W
I certify that in the performance of the work for which this permit is issued,I shall
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I h;reby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. wcrk'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 is
correct.I agree to comply with all city and county ordinances and state laws relating
uilding construction,and hereby authorize representatives of this city to enter
on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I ulderstand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-pom ource regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. ��
9.18. ur // Date
CITY OF CUE ERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 32644C39 . 00
DATE ISSUED. . . . . . . : 06/07/2010
RECEIPT #. . . . . . . . . BSOOOC10574
REFERENCE ID # . . . : 10060C27
SITE ADDRESS . . . . . : 10520 CASTINE AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : GARY W. & MARY TIETZ
ADDRESS 10520 CASTINE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1311
RECEIVED FROM . . . . : GARY 7IETZ
CONTRACTOR . . . . . . . : LIC: # *OWNER*
COMPANY . . . . . . . . . . : GARY Vt. & MARY TIETZ
ADDRESS . . . . . . . . . . : 10520 CASTINE AVE
CITY/STATE/ZIP . . . : CUPER-INO, CA 95014-1311
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----- ----- ---------- ---------- ----------
1BCBSC VALUATION 1, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1DEMOPRE SQUARE FEET 0 . 00 2:90 . 00 0 . 00 490 . 00 0 . 00
----- ----- ---------- ---------- ----------
TOTAL PERMIT 2:91. 00 0 . 00 491 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- - ------------------
CREDIT CARD 491 . 00 v:-sa
---------------
TOTAL RECEIPT 491. 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
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CITY OF CUPERTINO
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CUPEkTINO PERMIT APPLICATION FORM
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APN# �— Date:
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Building Address: /0,520
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Mailing Address (if different from building address):
Owner's Name: Phone:
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Contractor: Phone
Fax:
Contractor License #:
Cupertino Business License #:
Contact: Phone:
Fax:
Residential Sq Footage Commercial ❑ Sq Footage
Job Description:
Pool Dem o�, ars(nl
Valuation: //D() _
Project Size: Express ❑ Standard X 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 she(t index.
Quantity Fee ID Fee Description Fee Group Permit Type
IDEMORES Demo-Residential B 1SFDWL-DEM
IDEMOPRES ool Demo Residential B 1SFPOOL-DEM
IBCBSC Cal Bldg Standards B ALL PERMIT
Commission ee TYPES
IBSEISMICRE Seismic Residential B
Revised 01/07/09