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10020101CITY OF CUPERT INO BUILDING PERMIT BUILDING ADDRESS: 10876 ALDERBROOK LN CONTRACTOR: A TO Z POOL AND SPA REPAIR OWNER'S NAME: TIRUMALA MARRI 10289 MENHART LN NER'S PHONE: 4085056160 ❑ LICENSED CONTRACTOR'S DECLARATION License Class C' .S 3 Li,. # `% "It. 7� / Contractor WZ [ Date "?—Z, /z 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. 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 permit is issued. APPLICANT CERTIFICATION 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 relatir g 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 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 L-1 OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License. Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensatio i, 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 contractors tc construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three CUPERTINO, CA 95014 PERMIT NO: 10020101 DATE ISSUED: 02 /17/2010 PHONE NO: (408) 374 -6268 BUILDING PERMIT INFO: BLDG r ELECT F PLUMB r MECH r— RESIDENTIAL r— COMMERCIAL r— JOB DESCRIPTION: POOL DEMO (480SQFT) Sq. Ft Floor Area: I Valuation: $4500 APN Number: 36920034.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DA OM LAST CALLED INSPECTION. Issued by: l — Date: RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self - insure for Worker's California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain Compensation, as provided for by Section 3700 of the Labor Code, for the compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & performance of the work for which this permit is issued. Safety Code, Section 25532(a) should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance, as provided for by Additionally, should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code, for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued, I shall Health & Safety Code, Sections 25505, 25533, and 25534. • /� not employ any person in any manner so as to become subject to the Worker's Owner utp ed4 i�'"� �� / Compensation laws of California. If, after making this certificate of exemption, I --�� % Date: become subject to the Worker's Compensation provisions of the Labor Code, I mu >t forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 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 relatir g to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save unify and keep harmless the City of Cupertino against liabilities, judgments, , 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. I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 4 ITEMS OF 4 CITY OF CUPERTINO PERM CT RECEIPT Sec: Twp: Rng: Sub: B1k: Lot: APN ........: 36920034.00 DATE ISSUED.......: 02/17/2010 RECEIPT #.........: BS000009770 REFERENCE ID # 10020101 SITE ADDRESS ..... SUBDIVISION ...... CITY ............. IMPACT AREA ...... 10876 ALDERBROOK LN C'UPERTINO OPERATOR: patg COPY # : 1 OWNER "IRUMALA MARRI ADDRESS .0876 ALDER BROOK LN CITY /STATE /ZIP CUPERTINO CA, CA 95014 -4606 RECEIVED FROM A TO Z POOL & SPA R 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 -BAL --- - - - - -- 4,500.00 1.00 0.00 1.0 0.00 1BCBSC VALUATION 0.00 0.50 0.00 1BSEISMICR VALUATION 4,500.00 0.50 1BUSLIC FLAT RATE 1.0C 114.00 0.00 114.00 0.00 1DEMOPRE SQUARE FEET 480.00 490.00 0.00 490.00 - - - -- -0_00 TOTAL PERMIT 605.50 0.00 605.50 0.00 METHOD OF PAYMENT CASH TOTAL RECEIPT : AMOUNT 605.50 605.50 VOICE ID DESCRIPTION -- - - - - -- --------------- - 704 DEMO REFERENCE NUMBER -------------- - - - - -- VOICE ID DESCRIPTION -- - - - - -- ---------------------- - - - - -- CITY Of CUPEi�TINO octet CITY Off' CUPERTINO DEMO PERMIT APPLICATION FORM �h col, i C) c --,::2 ' 1 Q:13 \ APN# - > Fee ID Date: `7 //0 Building Address: Permit Type /o 4 --? (,, AI a �-•✓ 1DEMORES Mailing Address (if different from building address): B Owner's Name: J Phone: X B 50-5 — 6 6(f? Contractor: 1BCBSC Phone: B ALL PERMIT TYPES Fax: Contractor License t 7Y6 q-5-7 Seismic Residential Cupertino Business License #: Contact: � Phone: :? % e-31 Fax: Residential Sq Footage Commercial ❑ Sq Footage Job Description: c) Valuation: Z -t ev" Project Size: Express ❑ Standard tN barge ❑ 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 J 1DEMOPRES Pool Demo Residential B 1SFPOOL -DEM- 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09 CITY OF r:UPEk iNO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777 -3228 Fax (408) 777 -3333 Buildfing Department JOB ADDRESS: PERMIT #0 /p -7 6 /�e � /0b20 d OWNER'S NAME: ;/,.,�, ` PHONE # 505 6 i � a GENERAL CONTRACTOR: FAX # ? �I am not using any subcontractors: ��`Z `� Signature Date c „hrnnf-rnrf-nrS and rnrrinlete the following information: Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date