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10020129 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10675 GRAPNEL PL CONTRACTOR:XTREME CONCRETE PERMIT NO: 10020129 SOLUTIONS "NER'S NAME: DEL ROSARIO EDGARDO M AND REME 2189 SEPULVEDA AVE DATE ISSUED:02/24/2010 q—vNER'S PHONE: 4087337906 MILPITAS,CA 95035 PHONE NO:(408)594-3049 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG[— ELECT r— PLUMB r License Class Lic.# go 5-141 MECH r RESIDENTIAL r— COMMERCIAL Contractor (" )1�CO � Date O 1 I 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:$7900 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:32643057.00 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 WORD 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 granting of this permit. Additionally,the applicant understands and will comply with point rce regulations per the Cupertino Municipal Code,Section Issued by Date' 2'1 d 9.18 c.ana 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 I hereby affirm that I am exempt from the Contractor's License Law for one or inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensatior, Signature of Applicant: Date: 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 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the p alth&Saf Code,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I sha I� not employ any person in any manner so as to become subject to the Worker's \ Ow r au agent: I� Compensation laws of Califomia. If,after making this certificate of exemption,I Date. become subject to the Worker's Compensation provisions of the Labor Code,I mw 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 relatin; to building construction,and hereby authorize representatives of this city to enter Lender's Address ,n the above mentioned property for inspection purposes.(We)agree to save mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION ,.,,sts,and expenses which may accrue against said City in consequence of the grt' permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wit all on- - source regulations per the Cupertino Municipal Code,Section 9.1Licensed Professional Sig re Date1Ora CITY OF CUPERTINO 3 ITEMS OF 6 PERM: T RECEIPT OPERATOR: patg COPY ## 1 Sec: Twp: Rng: Sub: B'-k: Lot: APN 32643057. 00 DATE ISSUED. . . . . . . : 0:2/24/2010 RECEIPT #. . . . . . . . . B3000009812 REFERENCE ID # . . . 10020129 SITE ADDRESS . . . . . : 1 )675 GRAPNEL PL SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER DEL ROSARIO EDGARDO M AND REME ADDRESS . . . . . . . . . . : 1)675 GRAPNEL CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1319 RECEIVED FROM . . . . : RIGOBERTO R BELTRAN CONTRACTOR RIGO BELTRAN LIC # 29141 COMPANY . . . . . . . . . . : XPREME CONCRETE SOLUTIONS ADDRESS 2189 SEPULVEDA AVE CITY/STATE/ZIP . . . : MILPITAS, CA 95035 TELEPHONE . . . . . . . . : ( 108) 594-3049 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 7, 900 .00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 7, 900 . 00 0 . 80 0 . 00 0 . 80 0 . 00 1DEMOPRE SQUARE FEET 0 . 00 490 . 00 0 . 00 490 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 491. 80 0 . 00 491. 80 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO C', CITY OF CUPERTINO DEMO CUPEi�T1NO PERMIT APPLICATION FORM APN# Date: 0 Building Address: �— ptLtL br- Mailing Address (if different from building address): Owner's Name: 1'�`b Phone: y 9 3-3 Contractor: 1� Phone : L4 —5�1�3v L4 9 Fax: LW--7M 4 Contractor License #: Cupertino Business License#: Contact: Phone: q6y �jq-36L,q Fax. *0 Residential 2� Sq Footage Commercial ❑ Sq Footage Job Description: nQ � J; (1 Valuation: U0 Project Size: Express ❑ Stand 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-]Zesidential B 1SFDWL-DEM 1DEMOPRES Pool Di-.mo Residential B 1SFP00L-DEM_ 1BCBSC Cal B141g Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICRE Seismic; Residential B Revised 01/07/09 : Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -UPEkTINO Building Department JOB ADDRESS: Q � � ) J)� PERMIT # O OWNER'S NAME: a-ktm a 1v PHONE # U T9c1.30L1 GENERAL CONTRACTOR: ) �j FAX # - 1°/-1 1P I am not using any subcontractors: S.gnature Date Please check applicable subcontractors and corr plete the following information: SUBCONTRACTOR BUSDVESS 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 er ontractor Signature — ate