BLD-2020-07656/18/2020
CITY OF CUPERTINO BUILDING PERMIT
BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
W W W.CUPERT INO.ORG
BUILDING ADDRESS: 2189 Sepulveda Ave APN_ 362 06 017
PERMIT NO: BLD-202023765
OWNER'S NAME:
OWNER'S PHONE: Not Provided •
CONTRACTOR: X - TREME CONCRETE SO
CONTRACTOR PHONE: 4085943049
DATE ISSUED 6/18/2020 6:05:53 AM —1
ISSUED BY: JASMINE ARCHBOLD
VALUATION: $9C00
JOB DESCRIPTION
DEMOLISH IN -GROUND SWIMMING POOL - TO BE USED FOR LANDSCAPING PURPOSES ONLY.
LICENSED CONTRACTOR DECLARATION
CONTRACTOR: LICENSED CLASS: LICENSED NO: EXP DATE:
X-TREME CONCRETE SOL C-8 CONCRETE, D06 CON( 875417 03/31/2022
hereby affirm that I am licensed under the provisions of Chapter 9 (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 penatly of perjury one of the following three declarations:
I hove and will mointain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of he Lohor Coae, for the performance of the work for
which
this permit i5 issued.
V
I have and will maintain Workers Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I certify that in the performance of the work tor which this permit is issued, I shall not employ any person in any monger so as to become subject to the Worker's Compensation laws
of California.
this
If, after making this certificate of exemption. I become subject to the Worker's Compensation provisions of the Labor Code. I must forthwith comply with such provisions or
permit shall be deemed revoked,
HAZARDOUS
MATERIALS DISCLOSURE
V
I hove read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code Sections 25505, 75533, and 25534 I will maintain compliance with the
Cupertino
Mun,cipai Code, Chapter 9.12 and the Health & Safety Code. Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices
which
the
emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will mointain compliance with the Cupertino Municpal Code. Chapter 9.12 and
Health & Safety Code, Sections 25505. 25533, and 25534.
EPA
LEAD -SAFE DISCLOSURE
An EPA Lead -Sate Certified Renovator will be responsible for this project.
Certified
r 1 r
Fsrm Name: r r Firm Certification No: t i
' Rigo Beltran '
L J L J
V
No EPA Lead-Sofe Certified Firm is required for this project,
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work which this permit is issued (Section 3097. Civil Code).
D
Yes
No
r , r 1
Lender's Name: i Lender's Adaress: i i
1. J L J
APPLICATION CERTIFICATION
I certify that I hove read this application and state that the above information :s correct. I agree to comply with all city and county ordinances and state lows relating to building
construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (Wei agree to save indemnify and keep harmless
the City of Cupertino against liabilities. judgements. costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally. the applicant
understands and will comply witr all nor -point source regulations per the _i.perlinn, Munic pal Code Section 9.18.
Signature:
�
Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 days abler Hs issuance. or if the work authorized on the site by such permit Is suspended or abandoned tor a period o1 3A5
days after the IMne the work Is commenced
Submit
https://apps.cupertino.org/AcceIaIBLD-Sign-Permit.aspx?AccelaUser=ONETIMESIGN&OTK=9gcTfAAgVXtIHBXt1nDG84d0ekU77C2oa640U9wPowor .. 1/1