10050175 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10682 PEBBLE PL CO'4TRACTOR:XTREME CONCRETE PERMIT NO: 10050175
SOLUTIONS
'NER'S NAME: BUVNA SANGANALLI 218')SEPULVEDA AVE DATE ISSUED:05/24/2010
OWNER'S PHONE: 4088935666 MII PITAS,CA 95035 PHONE NO:(408)594-3049
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11COMMERCIALD
License Class
Li,.# `� POOL DEMO
Contractor Date -,-5M)D0)b
I hereby affirm that m 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.
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:$7500
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
AP:J Number:32643041.00 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. I agree to 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, ses which may accrue against said City in consequence of the
graofing of this a it. dditionally,the applicant understands and will comply Iss ied by: Date:
witfi all non-p into ce ulations per the Cupertino Municipal Code,Section
9.1!,8.
\ RE-ROOFS:
1
;Jture - Date !O 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
inspection.
❑ OWNER-BUILDER DECLARATION
Sig tature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I hive read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three ma ntain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's ma aerial. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. wil maintainetrberph2ace-Xvit the CthKrtmo Municipal Code,Chapter 9.12 a d
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&'Safety Code,Se s 2550 , 533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. ON ner or authorized ag Dat
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I he reby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. wo k's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
t-building construction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
_cmnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I widerstand 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 Lic,-nsed Professional
9.18.
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lct:
APN 32643041 . 00
DATE ISSUED. . . . . . . : 05/24/2010
RECEIPT # . . . . . . . . . BS0000I0468
REFERENCE ID # . . - : 10050175
SITE ADDRESS 10682 PEBBLE PL
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER BUVNA SANGANALLI
ADDRESS 10682 PEBBLE PL
CITY/STATE/ZIP . . . : CUPERT::NO, CA 95014-1333
RECEIVED FROM RIGOBERTO BELTRAN
CONTRACTOR RIGO BELTRAN LIC # 29141
COMPANY XTREME CONCRETE SOLUTIONS
ADDRESS 2189 SEPULVEDA AVE
CITY/STATE/ZIP MILPITAS, CA 95035
TELEPHONE (408) 594-3049
FEE ID UNIT QUANTITY AMOUK PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ----- ----- ---
1BCBSC VALUATION 7, 500 .00 1 . 00 0 .00 1 . 00 0 . 00
1BSEISMICR VALUATION 7, 500 . 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 491 . 80 visa
---------------
TOTAL RECEIPT 491. 80
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -------
704 DEMO
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME: .6Uh PHONE#
GENERAL CONTRACTOR: (1C{4� BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE: 4ft3
*Our municipal code requires a I businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUP NCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBC RACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signatur a Date
Please check applicable subcontractors and complete th� following information:
I/ SUBCONTRACTOR BUSINESS NikME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring /Carpeting
Linoleum/Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
O r ntractor Signature Date
CITY OF CUPERTINO
DEMO
CUPEkT1NO PERMIT APPLICATION FORM _
lOb� b I -75
APN# Date: /0^,d
Building Address: !-
Pz r� L
Mailing Address (if different from building address):
i'
Owner's Name: Phone:
Contractor: conCrt-k sa f� Phone :Vrew L4 bib 30 o
Fax:
Contractor License #: Lt7-7
Cupertino Business License#:
Phone:
Contact: P,i ?,rc)
� Ud/— �i —��jt,
', Fax:
Residential Sq Footage Conanercial ❑ Sq Footage
Job Description: P60L, D�e ma
Valuation: % 990
Project Size: Express Q/ Standard ❑ LargeEl 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-Resideitial B 1SFDWL-DEM
1DEMOPRES Pool Demo Ri;sidential B 1SFP00L-DEM_
f 1BCBSC Cal Bldg Standards B ALL PERMIT
1 Commission l7ee TYPES
1BSEISMICRE Seismic Resic.ential B
Revised 01/07/09
CITY OF CUPERTINO Bt ILDING PERMIT
BUILDING ADDRESS: 18996 PENDERGAST AVE CONTRACTOR:HENRY LITTLE TRACTOR PERMIT NO: 10040179
SERVICE
V -R'S NAME: VINCENT C WONG 14632 COLE DR DATE ISSUED:05/05/2010
'R'S PHONE: 4089306824 SAN JC SE,CA 95124 PHONE NO:(408)377-0504
❑ LICENSED CONTRACTOR'S DECLARATION BUILT:ING PERMIT INFO: BLDG f— ELECT r— PLUMB
License Class Lic.# MECH f— RESIDENTIAL F COMMERCIAL
Contractor Date
JOB DESCRIPTION:DEMO OF 1647 SQ FT SFDWL
I 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.
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:$7500
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
APN Number:37534039.00 Occupancy Type:
permit is issued.
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, 1f;0 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 all non-point source regulations per the Cupertino Municipal Code,Section Issued b l' Date:
9.18.
S ire Date
RE-ROOFS:
L OWNER-BUILDER DECLARATION All roe fs 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 of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signabire 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. 1 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 Addit onally,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
maint tin compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
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 revoked. CONSTRUCTION LENDING AGENCY
I here')y affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for wt ich this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lend:r's Name
correct.I agree to comply with all city and county ordinances and state laws relating
to''-•ilding construction,and hereby authorize representatives of this city to enter Lend,:r's Address
I le above mentioned property for inspection purposes.(We)agree to save
;mify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I undc rstand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date