09120027 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7852 BELKNAP DR CONTRACTOR:XTREME CONCRETE PERMIT NO:09120027
SOLUTIONS
0 "ER'S NAME: HARRY SUBAGIO 2189 SEPULVEDA AVE DATE ISSUED: 12/03/2009
O,#.NER'S PHONE: 4083156168 MILPITAS,CA 95035 PHONE NO:(408)594-3049
❑ LICENSED CONTRACTOR'S DECLARATIONr
� ) BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# p` ) r
MECH RESIDENTIAL COMMERCIAL
Contractor Date 19-1b
1 hereby affirm that'i am licensed under the provisions of Chapter 9 JOB DESCRIPTION: POOL DEMO&FILL
(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:$12000
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. APN Number:36210042.00 Occupancy Type:
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 relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
grantirlg.@kW ermit. Additionally,the applicant understands and will comply �Y-7
with C(ll non oint r egulations per the Cupertino Municipal Code,Section Issued b�v Date:/,/
t
Si_ -.0 Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION 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
1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. He ety Code,Sections 25505,25533,and 25534.
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 Own or a thoriz agent: ttd Q Q�
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 must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
u 'ie above mentioned property for inspection purposes.(We)agree to save
ii. aify and keepharmless the Ci '
of Cupertino against liabilities,judgments,
costs,and expenswhich may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CITY OF CUPERTINO 091 Z
DEMO
CUPEkT1NO PERMIT APPLICATION FORM
APN# U�4-2— Dat/9 3 O v J
Building Address:
Mailing Address (if different from building address):
Owner's Name: Phone:
44,rr 5u W )'b YOW -No_(VAO
Contractor: � e n Phone : L)oV_6q f 30q q
Fax: H0ty 71 q 1��
Contractor License #: 6
Cupertino Business License #:
Contact: ._J-2 r) Phone: L4 Y- qL/3a q
Fax: LJ 71q --�
Residential Sq Footage Commercial ❑ Sq Footage
Job Description: l- a-ry �r-i l
Valuation: )rj-,"
Project Size: Express ❑ Standard] Lange ❑ Major❑
Please complete relevant portions of the Greece 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-DEM_
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 01/07/09
Community Development
Sir
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
,UPEkTINO
Building Department
JOB ADDRESS: ,,. /�rl PERMIT #
OWNER'S NAME: PHONE # q
GENERAL CONTRACTOR: FAX # p -q �1- ) /(
I am not using any subcontractors: � 3 v
Si;;nature 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
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Date