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10010001 CITY OF CUPERTINO BUILDING PERMIT MET DR CONTRACTOR:XTREME CONCRETE PERMIT NO: 100 1000 1 BUILDING ADDRESS: 21438 M SOLUTIONS ANTHONY Y 2189 SEPULVEDA AVE DATE ISSUED:0 1/04/2010 OWNER'S NAME: WONG LOUISA M AND NER'S PHONE: 4082455768 MILPITAS,CA 95035 PHONE NO: (408)594-3049 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL. ❑ LI ENSED CONTRACTOR'S DEC L TION POOL DEMO AND FILL. License Class Lic.# Contractor 1 � Date I hereby affirm that am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Valuation:$7500 Code and that my license is in full force and effect. Sq.Ft Floor Area: I hereby affirm under penalty of perjury one of the following two declarations: Occupancy Type: 1. 1 have and will maintain a certificate of consent to self-insure for Worker's APN Number:32644004.00 Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by PER EXPIRES IF WORK IS NOT STARTED Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION. I certify that I have read this application and state that the above information is to comply with all city and county ordinances and state laws relating ---� ____ -- Date: 4•___. correct.1 agreep, . to building construction,and hereby authorize representatives of this city to save Issued b upon the above mentioned property for inspection purposes. (We)agreeave indemnify and keep harmless the City of Cupertino against liabilities,judgments, RE-ROOFS: costs,and expenses which may accrue against said City in consequence of the grant' ermit. Additionally,the applicant understands and will comply with All roofs shall be inspected prior to any roofing material being installed. If a roof is all no7-point sou regulations per the Cupertino Municipal C e,S ction 9.18. Installed without first obtaining an inspection,1 agree to remove all new materials for Ginspection. Signatu Date -- ------- - Signature of Applicant: Date: OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: HAZARDOUS MATERIALS DISCLOSURE 1. I,as owner of the property,or my employees with wages as their sole o the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the compensation,will d California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain sale(Sec.7044,Business&Professions Code) Chapter 9.12 and the Health& he property,am exclusively contracting with licensed contractors to complianceode Section 25532(a)should I Municipal a orhandlehazardous material. 2. 1,as owner oft p p Y� Safety Code, construct the project(Sec.7044,Business&Professions Code). Additionally,should I use equipment°ea Air Qualityr devices which emit hazardous air ct 1 will contaminants as defined by the Bay Chapter ment Dist and the I hereby affirm under penalty of perjury one of the following three declarations: maintain compliance with the Cupertino Municipal Code, 1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation,as provided for by Section 3700 of the Labor Code,for the C tl wn oruthor d a ent: 'Performance of the work for which this permit is issued. g Date: +2. 1 have and will maintain Worker's Compensation Ins ra ce,as work for which this for by Section 3700 of the Labor Code,for the performance permit is issued. CONSTRUCTION LENDING AGENCY 3. I certify that in the performance of the work for which this permit he IWo ker'shalereby affirm that there is a construction lending agency for the performance of work's not employ any person in any manner so as to become subject tot for which this permit is issued(Sec.3097,Civ C.) Compensation laws of California. If,after making this certificate of exemption,1 Lender's Name 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 Lender's Address ------- revoked. ARCHITECT'S DECLARATION APPLICANT CERTIFICATION I understand my plans shall be used as public records. 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 Licensed Professional to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save -unify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ..ng of this permit.Additionally,the applicant understands and will comply with aAlk - oint source gulations per the Cupertino Municipal Code,Section 9.18. Signatu Date CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: suew 3 ITEMS OF 3 COPY # 1 Rn Sec: Twp: g: Sub: Blk: Lot: APN 32644004 . 00 DATE ISSUED. . . . . . . 01/04/2010gS000009475 RECEIPT #. . " " • ' 10010001 REFERENCE ID # • • • SITE ADDRESS 21438 METEOR DR SUBDIVISION . . . . . . • CITY CUPERTINO IMPACT AREA ' • , . : WONG LOUISA M AND ANTHONY Y OWNER • . • „ 21438 METEOR DR ADDRESS . . . . . . . . . . . 21 CA 95014 CITY/STATE/ZIP • • • : CU 21 RECEIVED FROM . . . . : X-TREME CONCRETE LIC # 29141 CONTRACTOR . . . . . . . : RIGO BELTRAN COMPANY XTREME CONCRETE SOLUTIONS : 2189 SEPULVEDA AVE ADDRESS • • • • . . . . MILPITAS1 CA 95035 CITY/STATE/ZIP (408) 594_3049 TELEPHONE THIS REC NEW BAL T QUANTITY AMOUNT_-- -pD=TO_DT- -__------- ----_ __ _ - - FEE ID �I ---------- --- 1 . 00 p 00 1. 00 0 . 00 ---------- ---------- 7 500 . 00 1 . 00 0 . 80 0 .00 1BCBSC VALUATION 0 . 80 0 . 00 0 ,00 7, 500 . 00 0 . 00 490 . 00 1BSEISMICR VALUATION 0 . 00 490 . 00 ____------ 1DEMOPRE SQUARE FEET ------ 491 . 80 0 . 00 491 .80 0 . 00 TOTAL PERMIT AMOUNT REFERENCE NUMBER METHOD OF PAYMENT _--_----____ _____ ----------------- --- 491 .80 3363 CHECK --------------- 491 .80 TOTAL RECEIPT : VOICE ID DESCRIPTION ___ - --_----- VOICE ID DESCRIPTION-----_--- -______- ----------------- 704 DEMO CITY OF CUPERTINO DEMO CUPEIZTINO PERMIT APPLICATION FORM Date: � io rBuilrr# ding Address: t �w�kJ1`s (��-� , �Q�� Mailing Address (if different from building address): Owner's Name: Contractor: /�ZTrvu ConCr�"�'� Phone : L4 b Fes: Contractor License #: ��7'�� Cu ertino Business License#: ;�% G' Phone: Contact: ��..�j 'T3�j� qo,l- 7 ��_)�tiFax: Commercial ❑ Sq Footage Residential $.�_ Sq Footage --- Job Description: POOL..", ry M0 Valuation: Project Size: Express ❑ StandardLarge ❑ 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-Residential B 1SFDWL-DEM �+ 1DEMOPRES Pool Demo Residential B 1SFP00L-DE1Vr Cal Bldg Standards B ALL PERMIT f� 1BCBSC TYPES Commission Fee B 1BSEISMICRE Seismic Residential Revised 01/07/09 Community Development 10300 Torre Avenue s as Cupertino CA 95014 F -3228eepon _. .. Fax(408)777-3333 CITY 0 .,UPEkTINO Building Department JOB ADDRESS: PERMIT # �-M3 OWNER'S NAME: a PHONE # L40 Y-51� -3 4' GENERAL CONTRACTOR: ; FAX # qu L,-7) 1 11� ( 0 I am not using any subcontractors: Sign tore 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 � 1 Owner/Con actor Signature Da e