09080065 CITY OF CUPERTINO BUILDING PERMIT
0-11
BUILDING ADDRESS: 10384 DENISON AVE CONTRACTOR:XTREME CONCRETE PERMIT NO:09080065
SOLUTIONS
(1"41+R'S NAME: , 1�J?�Y�Ck? t, o t� �H89 SEPULVEDA AVE DATE ISSUED:08/10/2009
U7v,,%ER'S PHONE: 4082572712 MILPITAS,CA 95035 PHONE NO:(408)594-3049
❑ LICENSED CONTRACTOR'S DECLARATION
, rr A BUILDING PERMIT INFO: BLDG ELECT f— PLUMB
License Class "
Lic.# ��� '1 I If— �t—
RESIDENTIAL MECH RESIDENTIAL COMMERCIAL
Contractor G _ Date V
1 hereby affirm that Pam licensed under the provisions of Chapter 9 JOB DESCRIPTION:POOL DEMO& FILL-IN
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 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:$5000
1 have and will maintain Worker's Compensation Insurance,as provided for by
iSection 3700 of the Labor Code,for the performance of the work for which this APN Number:31629069.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify hat 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to bwld,ng construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FRIPM .LAST CALLED INSPECTION.
i indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs.acid expenses which may accrue against said City in consequence of the _ �i
granting of this permit. Additionally,the applicant understands and will comply Issued by: "v rte'`"'� Date: a ' v+ cq
{
wit l} source regulations per the Cupertino Municipal Code,Section
19.1 —
�.. .'"rz Date
l�
a
RE-ROOFS:
t� 'fll roofs shall be inspected prior to any roofing material being installed. If a roof is
❑ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,1 agree to remove all new materials for
hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons: `ignature of Applicant: Date:
1,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&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the the project(Sec.7044,Business&Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three 1 have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have Pnd will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the woi k for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
1 have and will maintain Worker's Compensation Insurance,as provided for by c)ntaminants as defined by the Bay Area Air Quality Management District I will
j Section 3700 of the Labor Code,for the performance of the work for which this n aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
r
I ealth&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
1 certify that in the performance of the work for which this permit is issued,1 shall C wne or uthor agent: �'
not employ any person in:any manner so as to become subject to the Worker's Date:
i Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked,
I iereby affirm that iliere is a construction lending agency f rr the performance of work's
f,,r which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION L.-nder's Name_
I certify that 1 have read this application and state that the above information is
correct. 1 agree to comply,with all city and county ordinances and state laws relating L!nder's Address
to building construction.and hereby authorize representatives cf this city to enter
( above mentioned_property for inspection purposes.(We)agree to save
i in, iify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,avid expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with ali non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. -
Signature Date
CITY OF CUPERTLvO BUILDING PERMIT
BUILDING ADDRESS: 10384 DENISON AVE CONTRACTOR:XTREME CONCRETE PERMIT NO:09080065
SOLUTIONS
(i"NER'S NAME: DENISE PABOFUNDA 2189 SEPULVEDA AVE DATE ISSUED:08/10/2009
(n. PER'S PHONE: 4082572712 MILPITAS,CA 95035 PHONE NO:(408)594-3049
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r- PLUMB r
License Class Lic.#
MECH RESIDENTIAL f- COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:POOL DEMO&FILL-IN
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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 Sq.Ft Floor Area: Valuation:$5000
performance of the work for which this permit is issued.
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:31629069.00 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. 1 agree 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:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
S: iture Date—
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
❑ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
1,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&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should 1 store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall Owner or authorized agent:
not employ any person in any manner so as to become subject to the Worker's Date:
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. 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.)
APPLICANT CERTIFICATION Lender's Name
1 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 Lender's Address
to building construction,and hereby authorize representatives of this city to enter
I he above mentioned property for inspection purposes.('Ale)agree to save ARCHITECT'S DECLARATION
h idly and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18,
Signature Date_
�T-D oolp �
CITY OF CUPERTINO
DEMO
CUPEkTINO PERMIT APPLICATION FORM
APN# sZ-q O (P v Date d a��
Building Address: r D
��'�
Mailing Address (if different from building adcxess):
Owner's Name: ti Phone:
9,,--r?-ra r7
Contractor: ,)/.�-�,�� �C vt k r � Phone : �1�- q .3� Gl
J� Fax: (44-76 6 —W409
Contractor License #: g 017
Cupertino Business License #:
Contact: '�1 �f Phone: q6y, 1? 36 q q
Fax: LW. r7f i - 14W
Residential Sq Footage Commercial ❑ Sq Footage
Job Description:
Valuation:
Project Size: Express ❑ Standar Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & th.- sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DE1Vr
1BCBSC Cal Blcg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B 7
Revised 01/07/09