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10020130 CITY OF CUPERTI ATO BUILDING PERMIT BUILDING ADDRESS: 10704 GRAPNEL PL CONTRACTOR:XTREME CONCRETE PERMIT NO: 10020130 SOLUTIONS `vNER'S NAME: ALYS HAY 2189 SEPULVEDA AVE DATE ISSUED:02/24/2010 . ..NER'S PHONE: 4087357228 MILPITAS,CA 95035 PHONE NO:(408)594-3049 ❑ LICENSED CONTRACTOR'S DECLARATION ��1� BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C Lic.# 14 R (.�,y� MECH r RESIDENTIAL r— COMMERCIALr Contractor I �� 'Jit/t• ► Date 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 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 permit is issued. APN Number:32643052.00 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 granting of this permit. Additionally,the applicant understands and will comply � wit - c' t source regulations per the Cupertino Municipal Code,Section Issued b / Date: 9.1 D Si-natur Date L l 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 o:' 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) 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. aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the p Hea &Safety ode,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I shall l not employ any person in any manner so as to become subject to the Worker's Own r 0 all ent: Compensation laws of California. If,after making this certificate of exemption,I < Date: 111 become subject to the Worker's Compensation provisions of the Labor Code,I mus: 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 anify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION catS,and expenses which may accrue against said City in consequence of the grthis permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wit :-1111 non- nt s ce regulations per the Cupertino Municipal Code,Section wit n 9.18. 1 _ , l () Licensed Professional Signature Date � CITY OF' CUPERTINO 3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: B].k: Lot: APN 3:643052 . 00 DATE ISSUED. . . . . . . : 0::/24/2010 RECEIPT #. . . . . . . . . BS000009812 REFERENCE ID # . . . : 10020130 SITE ADDRESS . . . . . : 10704 GRAPNEL PL SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER ALYS HAY ADDRESS 10704 GRAPNEL PL CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1319 RECEIVED FROM . . . . : R:CGOBERTO R BELTRAN CONTRACTOR R.EGO BELTRAN LIC # 29141 COMPANY XTREME 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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 983 . 60 VISA --------------- TOTAL RECEIPT 983 .60 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO CITY OF CUPERTINO I►EMO CUPEi�TINO PERMIT APPLICATION FORM APN# Date. �J Building Address: v6, G-7 r-rip ru. Mailing Address (if different from building adcress): Owner's Name: 1. Phone: d�f_v�3,15_-')9V Contractor: '�i � Phone : c46Y-5q y 3641 � - s C►(rt�e (5lt,�hO Fax: '-4--7M J P69" Contractor License #: kr?b-- {1 Cupertino Business License #: Contact: o ' t-tbK-"q 36�.f�f Phone: -�j -36q 9 Fax. � ResidentiaSq Footage Commercial ❑ Sq Footage Job Description: DfOA" O''m (' Valuation: Project Size: Express ❑ Standar4 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-lesidential B 1SFDWL-DEM ,6 1DEMOPRES Pool Di.-mo Residential B 1SFP00L-DENT / 1BCBSC Cal Bldg Standards B ALL PERMIT i� Commission Fee TYPES 1BSEISMICRE Seismic; Residential B I Revised 01/07/09 _ c Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -UPEkTINO Building Department JOB ADDRESS: o r?oq C-1rrp U L ))r— PERMIT# leg 4,22-0/ OWNER'S NAME: PHONE # q 0 3 0 44 GENERAL CONTRACTOR: FAX # qu —r))q—) I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI:vESS 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 �( to er/Contractor Signature Date