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09030230 CITY OF CUPERTINO BUILDING DIVISION PERMIT PERMIT NO. Tn BUILDING ADDRESS: 21431 ELM CT X—TREME CONCRET PERMIT ISSUE DATE OWNER'S NAME: TT nT1A99 CONTROL NO. 'ONE: (4 0 8) 5S4-3049 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH a p C LICENSED CONTRACTOR'S DECLARATION Job Description U1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Z5 with Section 7000)of D•ision3oftheBusincssandProcssiens / mylicensois POOL DEMO & FILL—X-TREME CONCRETE RENEW BUS LIC y in full force and eff Z License Cl co wr 3/31/9 t- Date ARCHITECTS DECLARATI N -r I understand my plans shall be used as public records m< DyU y Licensed pnrfessional u. OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the p 00 following mason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct.alter,improve,demolish,or repair any structure y^y prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q 6 8 0 0 tZ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 34152 that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500)• 3()2 01 0 1 l . 00 0 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 Required Inspections and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements anot intended or offered for sola If, are however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property.am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's U. cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. B&P C for this reason 0 1 am exempt under Sec Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of Consent to self-insure for Workers Compen- ation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which Ihis permit is issued. 01 have and will maintain Workers Compensation insurance,as required by Section 3700 of the Labor ode,for the performance of the work for which this permit is issued. My Wor m wCgp`l'nsuran carrier and Policy number am Carrier. i` Policy No.: CERTIFICATE EMPTION FROM WORKERS' COMP NSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) 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 Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Codc,you must ',Z' forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY (..,►.+ I hereby affirm that there is a construction tending agency for the performance of a> the work for which this permit is issued(Sec.3097,Civ.C.) W ALender's Name az Lenders Address U C) 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 Q Vbuilding construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. t W (We)agree to save,indemnify and keep harmless the City o(Cuperuno against VIliabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. ate / �' 3 1 ►-� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b SOURCE REGULATIONS. Re-roof: ✓��/� - Signature of Applicant/Contractor Dae 'j of Roof � HAZARDOUS MATERIALS DISCLOSURE YPe Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Mu 'pal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roof;shall be inspected prior to any rooTfmg-InakerbeingInst lied. yesNoIf a roof is installed without first obtaining an inspegree to remove Will the applican or future building occupant use equipment or devices which tit hazardous air contaminants defined by the Bay Area Air Quality Management all new naterials for inspection. istrict? ❑Yes I have read the hazardous materials requirements under Chapter 6.95 of due Califor- nia Health&Safcty Codc,Sections 25505,25533 and 25534.1 understand that if the building ntly have a tenant,that it is my responsibility to nouf the occupant of the Date re ireme w st be mel prior to issuance of a C ate of cup y S ignatul e of Appl icant All roof coverings to be Class'."or better Ow cr ora `� �� Date CITY OF CUPERTINO y ` DEMO CUPEk ANO PERMIT APPLICATION FORM APN# Date: Building Address: D- ;�- I `-�31 ��m C 1 Mailing Address (if different from building address): Owner's Name: Phone: H6 LS i/l, Oo Contractor: , f, Phone : L4(ffT 36( q 0 1v f�ayj )rzmt concr-Ae- Fax: L4 -7 sog Contractor License #: -� Cupertino Business License #: ' 9 Contact: o j Phone: lqay—,6 tq.-3d f 1M ,vl- Fax: rlJ Residential Sq Footage Commercial ❑ Sq Footage Job Description: Dew LAI Valuation: Project Size: Express ❑ Standard 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 i 1DEMOPRES Pool Demo Residential B 1SFPOOL-DEM 1BCBSC Cal Bldg Standards B ALL PERMIT T Commission Fee TYPES / 1BSEISMICRE Seismic Residential B Revised 01/07/09 Community Development 10300 Torre Avenue ,y Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CITY OF r,UPERTINO BuildinDe artment JOB A JAR, S�S� / � PE of '7RMIT # � 0 03 23d OWNER'S NAMEPHONE # GENERAL CONTRACTOR: 't Z� FAX # G -� 1 d I am not using any subcontractors: Signa e Date Please check a licable subcontractors and com Mete the followinginformation: SUBCONTRACTOR BUSI NESS 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