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10010036 CITY OF CUPERTINO BUILDING PERMIT CONTRACTOR:XTREME CONCRETE PERMIT NO: 10010036 BUILDING ADDRESS: 1104 ELMSFORD DR SOLUTIONS 2189 SEPULVEDA AVE DATE ISSUED:01/08/2010 NWNER'S NAME: RAKHAU&ARVIND MANIDANNE PHONE NO:(408)594-3049 MILPITAS,CA 95035 OWNER'S PHONE: 4088069514 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL 0 LICENSED CONTRACTOR'S DECLARATION T* POOL DEMO License �- Lic.# Contractor Date �/ 0 I hereby affirm that I a licensed under the provisions of Chapter 9 (commencing with Section 7000)of Divisionand effect.f the Business&Professions Code and that my license is in full force I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to sef-insure Labor CodWorker's Compensation,as provided for by Section 3700 of theValuation:$13500 [SEq.Ft Area: :Floor performance of the work for which this permit is issued. provided for b I have and will maintain Worker's Compel performancesation ofthe work for which this Occupancy Type: Section 3700 of the Labor Code,for the p APN Number:36206003.00 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 STARTS correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE O p y to to building construction,and hereby authorize representatives of this tto saver 180 DAYS FROM LAST CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We)agree _ indemnify and keep harmless the City of Cupertino against liabilities,judgments, against said Ci in consequence of the ,w... Date: costs,and expenses which may accrue agar ty Issued by. granting of this permit. Additionally,the applicant understands and will comply with-all oint sourc regulations per the Cupertino Municipal Code,Section 9.18. ) RE-ROOFS: Date 10 �� All roofs shall be inspected prior to any roofing material being installed.If a roof is gnatur installed without first obtaining an inspection,I agree to remove all new materials for inspection. [) OWNER-BUILDER DECLARATION Date: Signature of Applicant: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, nded or offered for sale(Sec.7044, will do the work,and the structure is not inteMATER DISCLOSURE Business&Professions Code) HAZARDOUS MAT I,as owner of the property,am exclusively contracting with licensed contractors to &Professions Code). I have read the hazardous materials srequirements under Chapter and 25534.91 of the construct the project(Sec.7044,BusinessCalifornia Health&Safety Code,Section one of the following three maintain compliance with the Cupertino Municipal ore or handle Chapter 9.12 and the I hereby affirm under penalty of perjury o Health&Safety Code,Section 25532(a)show ld declarations: Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous I have and will maintain a Certificate of Cons Chapter 9.12 and Labor Code,for the air contaminants as defined by the Bay Area Municipal Code, District Compensation,as provided for by Section 3700 of the La will maintain compl' ' h the Cupertino P performance of the work for which this permit is issued. provided for by the Health&Safety •ode,Secti 5 5,25533,and 25534. I have and will maintain Worker's Compensation Insurance,asp Date: 6 ) Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ag permit is issued. I certify that in the performance of the work for which this permit�e issued, Worker'sshall RUCTION LENDING AGENCY not employ any person in any manner so as to become subjectCONST Compensation laws of California. If,after making this certificate of exemption,I visions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance Of become subject to the Workers Compensation pro work's for which this permit is issued(Sec.3097,Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. 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 a ves of this state city t s entering to building construction,and hereby authorize rep ARCHITECT'S DECLARATION n the above mentioned property for inspection purposes.(We)agree to save .emnify and keep harmless the-City of Cupertino against ti d City inconsequenceof the ts, I understand my plans shall be used as public records. costs,and expenses which may accrue ag licant understands and will comply granting of this permit.Additionally,the app Lth t so ce regulations per the Cupertino Munici 1 Code,Section Licensed Professional re Date t Community Development { 10300 Torre Avenue j}- Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 CIT1(OF .,,,'UPEkT1N0 Build' D e arum a nt in OB ADDRESS: PERMIT #0 L/ (�5LVO 5 br PHONE # OWNERS NAME: rVY, 6 N � L46 GENERAL CONTRACTOR t FAX# I am not using any subcontractors: Date Please ch Sign tore check applicable subcontractors and com Tete the f DRowing information: BUSINESS NAME BUSINESS LICENSE # SUBCONTRACTOR 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 lQ Date ';Ote Contractor Signature CITY OF CUPERTINO OPERATOR: SylviaM 3 ITEMS OF 3 PERMIT RECEIPT COPY # � 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36206003 . 00 DATE ISSUED. • • • • " 01/08/2010 RECEIPT # • • " ' 10010036 REFERENCE ID # • • • SITE ADDRESS 1104 ELMSFORD DR SUBDIVISION CITY . . . . . . . . . . • • . • CUPERTINO IMPACT AREA . . . . . . • gp,KHAU& ARVIND MANIDANNE OWNER • " " • 1104 ELMSFORD DR ADDRESS • • • • • • . . CUpERTIN0 CA, 95014-4909 CITY/STATE/ZIP • • • RECEIVED FROM . . . . : RIGOBERTO BELTRANC # 29141 CONTRACTOR . . . . . . . : RIGO BELTRAN ANY XTREME CONCRETE SOLUTIONS COMP : 2189 SEPULVEDA AVE ADDRESS MILPITASCA 95035 CITY/STATE/ZIP • • ,(408) 594-3049 TELEPHONE . . . . . . . • THIS REC NEW BAL AMOUNT PD-TO-DT _ QUANTITY ----- FEE ID UNIT----- ---------- ---------- ---------- --------- ---- 0 . 00 ----- 1 . 00 0 .00 0 . 00 VALUATION 13, 500 . 00 0 . 00 1.40 1BCBSC 13, 500 .00 1.40 490 . 00 0 .00 1BSEISMICR VALUATION 0 . 00 490 . 00 0 . 00 ___ --_-______ 1DEMOPRE SQUARE FEET _________- ---------- 492 .40 0 . 00 492 .40 0 .00 TOTAL PERMIT AMOUNT REFERENCE NUMBER METHOD OF PAYMENT --------------- ____ _ ----------------- 492 .40 visa CREDIT CARD _______________ 492 .40 TOTAL RECEIPT VOICE ID DESCRIPTION ___ ___- _______ VOICE ID DESCRIPTION--- ---- --___-__ ------------------ 704 DEMO CITY OF CUPERTINO f DEMO CiTMof PERMIT APPLICATION FORM CUPEI�TINO1 0o I oo-�{o APN# Date: i Building Address: 1f0q �m S�r Dr- Mailing Address (if different from bwilding address): 5,� Owner's Name: ��- �G1 Wh l �(1 Y1 Phone: ��—�'tj(P-- —�SI ar V Contractor: "�_co(I��' :S 0)v �n f Phone : c/6 --�P36 Fax: Contractor License #: Cu ertino Business License#: Phone: c40 -b-'iN 7,36 Lt� Contact: ��c�,fi j�j,��'1 Fax: Footage Commercial ❑ Sq Footage Residential Sq g _- Job Description: Valuation: Project Size: Express ❑ Standard Large ❑ Major❑ Please complete relevant portions of the Green Checklist & attach it to the application or if applicable, include on the pan et & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residential B 1SFDWL-DEM 1DEMOPRES Pool Demo Residential B 1SFPOOL-DE1V7 / ALL PERMIT 1BCBSC g Cal Bldg Standards TYPES Commission Fee B 1BSEISMICRE Seismic Residential Revised 01/07/09 )ENTER PROJECT NAME Enter description here,and enter points available for measure In appropriate categories to ft'right Enter description here,and enter points available for measure In appropriate categories to the rIght. Enter description hem,and enter points available for measure In appropriate categories to the right. 0 0 0 0 Enter description hem and enter points available for measure in appropriate categories to the right. RIJN It Q gpen Checklists and that meet the green building objectives of the Guidelines.Enter up to a Gnt ildelines- 4.Innovation:List innovative measures suggested measures,using the link to the right. combined total of 20 pts.See Innovation Checklist for - maximum cOm0 0 0 0 0 Innovation in Community:Enter description hem,and enter points available for measure in appropriate categories to the right. - ...... 0 0 0 0 0 0 Innovation in Energy:Enter description hem,and enter points available for measure In appropriate categories to the right. ria categories the right 0 0 0 A Innovation in IAQfHeafth:Enter description here,and enter points available for-measure in appropriate catego as to 0 00 able for measure In appropriate.propriate categories to the t 0 ht. .I—-1.1-1-11- 0 - -- - Innovation In Resources:Enter description hem,and enter points avail Innovation in Water:Enter;;;;p n hem,and enter points available for measure In appropriate categories to the right. Total Available Points in Other 0 4'A 66+ 43+ 4+ 96+ 42+ Total Available Points in Specific Categories* L 1 1 - - 1 0 Minimum Points Required in Specific Categories 30 5 6 9 01 0 0 0 1 0 0 Total Points Achieved Project has not yet met the following recommended minimum requirements: - Total Project Score of At Least 50 Points - Required measures: -A3a: 50%waste diversion by weight -32: 1501b above Title 24 -NI:Incorporate GreenPoint Rated Checklist into blueprints Minimum points in specific categories: 1. -Energy(30 points) -IAQIHealth(5 points) -Resources (6 points) -Water(9 points) 0 2007 Build It Green Single Family GreenPoint Cheddist 2007 Version Page 7 of 7