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10100162 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10674 GRAPNEL PL CON TRACTOR:XTREME CONCRETE PERMIT NO: 10100162 SOLUTIONS "NER'S NAME: ROBERTSEN KU 2189 SEPULVEDA AVE DATE ISSUED: 10/21/2010 u WNER'S PHONE: 4083380364 MIL]'ITAS,CA 95035 PHONE NO:(408)594-3049 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lip.# r) r— F MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that am licensed under the provisions o Chapter 9 JOB DESCRIPTION: POOL DEMO&FILL (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.F t Floor Area: Valuation:$7000 I have and will maintain Worker's Compensation Insurance,as provided for Section 3700 of the Labor Code,for the performance of the work for wh' tlu permit is issued. APN Number:32643050.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above in atio is correct.I agree to comply with all city and county ordinances and sta ting 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, 80 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the grant' f this permit. Additionally,the applicant understands and will comply wit i all no t sou a regulations per the Cupertino Municipal Code,Section Issu�:d by f Date• f t �D at Date�� J RE-ROOFS: ❑ OWNE -BUILDER DECLARATION All rc,ofs shall be inspected prior to any roofing material being installed.If a roof is instal led 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 inspe:tion. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Sign,ture 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 hay a 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 Calif urnia Health&Safety Code,Sections 25505,25533,and 25534. I 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. Safes y Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided f y Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for whic this rlk�:nants as defined by the Bay Area Air Quality Management District I will m ntg ance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. l:h&Safe ode,Sections 25505,25533,and 25534 I certify that in the performance of the work for which this permit is issued,I s 11 not employ any person in any manner so as to become subject to the Worker'sr or ent: ,&i Compensation laws of California. If,after making this certificate of exemption,I Date: �� I become subject to the Worker's Compensation provisions of the Labor Code,I must J forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I herr by affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for w hich this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Len(er's Name correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter Lenc er's Address the above mentioned property for inspection purposes.(We)agree to save .mify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I and erstand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18• Liceiused Professional Signature Date DEMOLITION CITY OF CU PERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$7,000 ;PERMIT TYPE: Demolition Permit 's, ("!;t=?-'K 1)"I'l- PRIMARY SwimmingPool, Res. T PENTAMATION 1SFP00LDEM USE: PERMIT TYPE: WORK SCOPE FEE ID #POOLS 1 DEMOPRES 'I -T'c:,i. r.�l�t7fi` C)t,rte, > of r�F-°.;� f.I�-�=r�� O7,'r�t . Irrs��. i."� h If v) 1`c", (�t r3a7�. Tii I t',.' lsiet.Imp Fc' NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn 7 info. FEEL ITEMS(F �'. /71/10)ee Resolution 09-OSI E �7i10) FEE QTY/FEE MISC ITEMS Check he ck /e nett/Jp[ 1l{ /'cc F71 'A f'lzlrrzh..: 1��c17.%I�lc�� Phin Permit Fee: $291.00 Suppl. Insp. Fee.0 Reg. 0 OT0.0 hrs $0.00 C'rrit/"('(% Pc'rulil1'cc': C.`onso-11crion Tax I<:ot�_strc;crl Rcrico Vcc. lf'o 1, 11"ithozrt f'ct rt�it' I'lrrr�r�itt,<� f cg's: Ooctolie oliott Fccs Strong Motion Fee: 1BSEISMICR $0.70 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $292.70 $0.00 TOTAL FEE: $292.70 Revised: 10/17/2010 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: I,ot: APN . . . . . . . . : 32643050 . 00 DATE ISSUED. . . . . . . : 10/211'2010 RECEIPT #. . . . . . . . . : BS000011810 REFERENCE ID # . . . : 10100_.62 SITE ADDRESS . . . . . : 10674 GRAPNEL PL SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPER-INO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : ROBER-SEN KU ADDRESS . . . . . . . . . . : 10674 GRAPNEL PL CITY/STATE/ZIP . . . : CUPER"INO, CA 95014 RECEIVED FROM . . . . : RIGOBERTO R BELTRAN CONTRACTOR . . . . . . . : RIGO BELTRAN LIC # 29141 COMPANY . . . . . . . . . . : XTREME CONCRETE SOLUTIONS ADDRESS . 2189 S)EPULVEDA AVE CITY/STATE/ZIP . . . : MILPI"AS, CA 95035 TELEPHONE . . . . . . . . : (408) 594-3049 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- 1BCBSC VALUATION 7, 000. 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 7, 000 . 00 0 . 70 0 . 00 0 .70 0 . 00 1DEMOPRE EACH 1 . 00 291. 00 0 . 00 291. 00 0 . 00 ---- ------ ---------- ---------- ---------- TOTAL PERMIT 292 .70 0 . 00 292 . 70 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CREDIT CARD 292 .70 V:-SA --------------- TOTAL RECEIPT 292 .70 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO Building Department 1[a City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: low?7 PERMIT# < OWNER'S NAME: we� PHONE# GENERAL CONTRACTOR: I qt P 1 BUSINESS LICENSE# ) ADDRESS: 91AP SeAl fQ CITY/ZIPCODE: q j' *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR fD AL CUPANCY I S PECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR TRA TORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontrac -- Sign a Date Please check applicable subcontractors and complete the following information: s/ SUBCONTRACTOR BUSINESS NAME 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 %1 /Co ra ature Date CITY OF CITERTINO DEN[O CUPEkTINO PERMIT APPLICrATION FORM APN# .C�-P jj // � Date: f,� f 0 � / Building Address: SCA V ��pt 01 7 Mailing Address (if different from building address): Owner's Name: iu) Phone: Contractor: x lrimt coot t �bl v- i y S Phone : -, ��`� bC,-1-hf1Fax: ��_ 71�i JJ79- Contractor License #: 9 Cupertino Business License #: Contact: Phone: Fax: 40,Y-71y "I Wp - Residential Sq Footage Commercial ❑ Sq Footage Job Description: PW-,- k,Mt Valuation: krmn Project Size: Express ❑ Standar Large [] 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-DEM- 1BCBSC Cal Bldg Sta idards B ALL PERMIT Commission Fee TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09