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09060147 CITE'OF CUPERTINO BUILDING DIVISION PERMIT l✓� Rlx ��� T� 1lr PERMIT NO. BUILDING ADDRESS: 19731 BIXBY DR XTREME CONCRETE L PERMIT ISSUE DATE OWNER'S NAME: �'rTAn uAlac. T TIT S A CONTROL NO. INE: (408) 594-3049 BUILDING PERMIT INFO ARCH17ECTIENGINEER: BLDG ELECT PLUMB MECH p ZO LICENSED CONTRACTOR'S DECLARATION Job Description u p I hereby affirm that I am licensed under provisions of Chapter 9(commencing 8 with Section 70(10)of Division 3 of the Business and Profcssia s Code,and my license is POOL DEMO & FILL rn in full force and effect � (�i v�z License Class Lte• Dam ConuacWr ARCHITECTS DECLARA I a< 1 understand my plans shall be used as public records yU u.y Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the :00 following mason.(Section 7031.5,Business and Professions Code:Any city or county li which requires a permit to construct.alter,improve,demolish,or repair any structure in prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area [_G (commencing with Section 7000)of Division 3 of the B usincss and Professions Code)or 7 5 0 0 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APr i Number Occupancy Type not more than five hundred dollars(M). 36909047 . 00 ❑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 Contractor's License Law docs not apply to an owner of q p property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, 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 Contractors Li- 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 Contractor's License Law. ❑1 am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My W s C t eOsauon Insurance carrier and Policy nu�gher are:ERI 1 TE OF EXEMPTION FROM WORKERS' COMPENSATION 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 at 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 Code,you must .J O forthwith comply with such provisions or this permit shall be deemed revoked. Z , CONSTRUCTION LENDING AGENCY rA [.4 I hereby affirm that there is a construction lending agency for the performance of P„> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lenders Name Z Lenders Address U C I certify that 1 have read this application and state that the above information is corccL 1 agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes Oa (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way scenic against said City in e c V z ranting of this permit Date � - I PP ICA UNDER S AND WILL COMPLY WITH ALL N N-POINT Issued by: SOU E R G LA 0 S.•. f(� u/ Re-roofs Si of A UContractor lbate AZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall t e inspected prior to any roofing material being installed. ❑Yes No If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes N° 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- n' Safety Cade, tions 25505.25533 and 25534.I understand that if the building does of cu ntly have a ant,that it is my responsibility to notify the occupant of the requi ,nem ,tat met prier to issuance of a Certificate of Occupancy. Signature of Ap)lieant Date owne orauthoriz \agcnl'� ------ Daae _ All roof coverings to be Class'A.'or better CITY OF CUPERTINO DEMO CUPEI�TINO PERMIT APPLICATION FORM APN# © ZA4 C) Date: Iqleq Building Address: l !�l PDJ k , Dr Mailing Address (if different from building address): Owner's Name: Lid Phone: d Contractor: ?)pp -PyC,1*ZQ11 Phone : L40 >(7ptio- ��CM r S�U�7c1� Fax: L 71ct - [hog Contractor License #: n 5q l Cupertino Business License #: Contact: i Phone: i�0too �-30 y g Ili Fax: HHV- -7r9- 1of&6 Residential ' Sq Footage Commercial ❑ Sq Footage Job Description: -ep�0 � A ,-)LV%M illi RV Valuation: q 560.. Project Size: Express ❑ Standard'-'oLarge [] Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheat index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residc:ntial B 1SFDWL-DEM 1DEMOPRES Pool Demo Residential B 1SFP00L-DEM 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09 Community Development r 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �,UPEkTINO Buildin , De artment JOB ADDRESS: I �ToC � �� PERMIT # OWNER'S NAME: 51ad Liu PHONE # v °lklp rj.4N q GENERAL CONTRACTOR: r-� FAX# -F��-7l -I I am not using any subcontractors: Signature Date Please check applicable subcontractors and com Tete the following information: -]21 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 ' e Own Con actor Signature Date