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09040038 CITY OF CUPERTINO BUILDING DIVISION PERMIT � '� � I�EJ�ZMTII�1 _. PERMIT NO. BUILDING ADDRESS: 7675 ERIN WAY XTREME CONCRET PERMrr ISSUE DATE OWNER'S NAME: SW T All S A CONTROL NO. ')NE: (408) 594-3049 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH app LICENSED CONTRACTOR'S DECLARATION Job Description U I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 70(1))of Divi i n 3 of the Business and Professions Co and my license is POOL DEMO & FILL LU n<y in full force and effec 5n? License Class Lic. 3 y O Date Con RCHITECTS DE-LA -� I understand my plans shall be used as public records DU U.y Licensed Professional n y OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the COO following reason.(Section 7031.5,Business and Profewons Code:Any city or county K l4 9 which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation A] P Ft.Floor Area 2:2,<C that he is licensed pursuant to the provisions of the Contractor's Lit.ense Law(Chapter 9 Sq Y. t-a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5800 y 9.. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars(5500). 359200',.4 . 00 0 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 oroffered for sale(Sec.7044.Business Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements arc not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). 0 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's U. cense Law does not apply to an owner of property who builds or improves thereon,Ind, who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. 0 1 am exempt under Sec. B dt P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- ..etion,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Wor Compe anon Insurance carrier and Policy nu r are: Carries DYh PoI'rry No.. C19011710ZE 0 CEMPTTON FROM WORKERS' COMP SATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less) 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 Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of a the work for which this permit is issued(Sec.3097,Civ.C.) LIa Q Lender's Name =Z Lender's Address U C) I certify that I have read this application and state that the above information is LL 04 correct.1 agree to comply with all city and county ordinances and state laws relating to 0 U building construction.and hereby authorirs:representatives of this city to enter upon the W above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against HC/] liabilities,judgments,costs and expenses which may in any way accrue against said City t U,'� m con of a granting of this permit. Date ►-r APPLIC STANDS AND WILL COMPLY WITH ALL O POINT Issued b is SOURCE EGU TT v Re-roofs �-- Signaturc o pplicam/Con D T of Roof HAZARDOUS MATERIALS DISCLOSURE ype Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Mu ipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. 0 Yes �p No / If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which it hazardous air contaminants defined by the Bay Arca Air Quality Management all new materials for inspection. .Suitt? 0 Yes No 1= read the by rus materials requirements under Chapter 6.95 of the Califor- Ith& t Codc,Sections 25505,25533 and 25534.1 understand that if the building docs of ndy ve a tenant.that it is my responsibility to no' the upant of the reyui men which be met prior to issuance of a Ccrtific p �{• Signatur-.of Applicant Date (f All roof coverings to be Class" "or better O r au Date CITY OF CUPERTINO DEMO CUPEkTiNO PERMIT APPLICATION FORM APN# � � Date: -J Building Address: Mailing Address (if different from building address): Owner's Name: Phone: S 09AvI3-41N 5Z Contractor: G,� "14y�k coo -� s dluPhone : OW-544-,30L41 Fax: Contractor License #: g r76z4)q Cupertino Business License#: Contact: i Phone: t�� Fax: y'QY' 71� --1� Residenti Sq Footage Commercial ❑ Sq Footage Job Description: P4 L", A n-1 A-1 f Valuation: Project Size: Express ❑ Standard Large ❑ Major ❑ Please complete relevant portions of the Gre-.n 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-DEM 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES i 1BSEISMICRE Seismic Residential B Revised 01/07/09 2 CITY OF CUPERTINO j. DEMO PEkT CUiNO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group Permit Type 1DEMOCOM Demo-Commercial B 1COMML-DEM 1DEMOPCOM Pool Demc Commercial B 1CP00L-DEM 1BCBSC Cal Bldg Standards B ALL PERMIT Y Commission Fee TYPES 1BSEISMICOM Seismic B 1BUSLIC Business License B Revised 01/07/09 s,;.. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 0TV OF Fax(408)777-3333 (. UPERTINO Buildi[ng Department JOB ADDRESS: t7u r?S— (any) W� PERMIT #'� 69U L4 00:39 OWNER'S NAME: S L-a 0 PHONE # 1-,!Y5q-6q cl GENERAL CONTRACTOR: G FAX # *) •-71 c I am not using any subcontractor /-7 Id 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 Owner/Contractor Signature Date