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12090135CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR 219E CONPRACPOR: MISSION VALLEY PERMIT NO: 12090135 ELECTRIC INC OWNER'S NAME: ANNA SMITH PO BOX 3332 DA'Z'E ISSUED: 09/142012 OWNER'S PHONE: 650944-010 FREMONT, CA 94539 PHONE NO: (510) 745-8847 ❑ LICENSED CONI'RACI'OR'S DECLARATION .JOB DESCRIPTION: RESIDF,N I'IAI, 11 COMMERCIAL❑ License Class Lic.q LI%U I3 % INSTALL 6 LED LIGHTS AND REPLACE 10 SWITCHES Q Contractor Date ! —( L(- (Z AND 20 REEPTICLES, REPLACE EXHAUST FAN AND INSTALL 1 hereby a irm that I am licensed under the provisions of Chapter 9 HEAT LAMP (commencing with Section 7000) of Division 3 of the Business 8 Professions Codt e and that my license is in full force and effect. 1 hereby affirm under penally of perjury one of the following heo 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 Sq. Ft Floor Area: Valuation: $4000 performance of the work for which this permit is issued. I have:md will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the perfan nance of the work for which this AI'N Number: 34253083.00 OccupancyType: permit is issued. ,APPI,ICAN'1' CER•rJFIC 'I'ION I certify that 1 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 stale 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, and expenses which may accrue against said City in consequence of the -'–) G+ granting of this permit. Additionally, the applicant understands and will comply =�� Issued by: / /� E Date: / % / p— with all non -point sour a regulations per the Cupertino Municipal Code, Section 9.18. RF: ROOFS: Signature ate 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 Signature of Applicant: Date: hereby affirm that I am exempt from the Contractor's License Law Formic of the following two reasons: AI,I, ROOF COVERINGS TO RIS CLASS "A" OR BETTER I, as ownerof the property,•or my cnnployccs with wages as their sole compensation, will do the work, and the structure is not intended or offered far sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to IIA'J,ARDOUS MATERIALS DISCLOSURE construct the. project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California llcallh & Safety Code, Sections 25505, 25533• and 25534. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance a ilh the Cuperlinn Municipal Code, Chapter 9.12 and the declarations: Health 3 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 material. 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 performance of the work for which this permit is issued, will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the l lealth S Safeq Code. Section .4505, 255 3. and 25534. Section 3700 of the Labor Code, for the performance of the work for which this 7 permit is issued. Owner or authorized agent:ale: I certify that in the performance of the work for which this permit is issued, 1 shall not employ my person in any manner so as to become subject to the Worker's Compensation laws of Cal ifarma. If, after making this certificate of exemption, I CONSTRUCFION LENDING .AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that 1 have read this application and state that the above information is cored. I agree to comply with all city and county ordinances and stale laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. ('Ale) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHI'1•F.CLS DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand 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 Licensed Professional 9.18. Signature Date CITY OF CUPERTINO ISI FEE ESTIMATOR—BUILDING DIVISION WFADDRESS: 23500 Cristo Ret Dr. DATE: 09/14/2012 REVIEWED BY: Sean UNITS APN: BP#: /1)1090/35- 1 'VALUATION: $4,000 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $67 PENTAMATION 1REAP11 PERMIT TYPE: WORK Installation of 6 LED lights and replace 10 switches and 20 receptacles, replace exhaust fan and SCOPE install heat lamp. APPLIANCE/ EQUIP TYPE FEE ID Plumb. Plat) Check QTY UNITS BP FEES Elec. Permit Fee: IEPERAIIT Fixtures, Lighting 1BREMFIXT Other Elec. Insp. OA hrs $45.00 8 # $67 Recep/Switch/Outlets 1BREMRECEP Suppl. Insp Fee 30 # $85 PML' Unit Fee: $152.00 PME Permit Fee: $45.00 Consnrtction Tax: Administrative Fee: 1AWfly $42.00 Work Without Permit? Yes Q No $0.00 TOTALS: Travel Documentation Fee: ITRAPDOC $152.00 Strong, Motion Fee: IBSCISAIICR NOTE: This euinmte doer not include jecv due to other Departments (i.e. Planning, Public If orks, Fire, Sanitary Server District, School District. etc.). These fees are based on the nreliminare information available and are onh, an estinote. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 Ell' 7/1/11) Meth. Plan Check Plumb. Plat) Check Elec. Plan Check 1 0.0 1 hrs $0.00 ,tfech. Permit Fee: Plumh. Permit rec., Elec. Permit Fee: IEPERAIIT Other Mech. Imp. Ocher Plumb Insp. Other Elec. Insp. OA hrs $45.00 14ech. Insp. Fee: Pluwh. hup. Fre: Flee. Insp. Fee: NOTE: This euinmte doer not include jecv due to other Departments (i.e. Planning, Public If orks, Fire, Sanitary Server District, School District. etc.). These fees are based on the nreliminare information available and are onh, an estinote. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 Ell' 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee PML' Unit Fee: $152.00 PME Permit Fee: $45.00 Consnrtction Tax: Administrative Fee: 1AWfly $42.00 Work Without Permit? Yes Q No $0.00 Advancer! Planning Fees: Travel Documentation Fee: ITRAPDOC $45.00 Strong, Motion Fee: IBSCISAIICR $0.50 Select an Administrative Item Bldg Stds Commission Pee: 1BCBSC $1.00 SUBTOTALS: $285.50 $0.00 TOTAL FEE: $285.50 Revised. ( CUPERTINO CONSTRUCTION PERMIT APPLICATION CONINIUNIIY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 / '� D c/o/35 (408) 777-3228 • FAX (408) 777-3333 - buildina(dOcuoer'Jno-oro n NEW CONSTRUCTION F� ADDITION r��rr�t Z-- ❑ ALTER.Al10N / TI ❑ REVISION / DEFERRED ORGINAL PEF-k= 4. PROIzCTADDRSS2z SO� c rZ1 S %� 1 R— I �x J VNI -1 - OWNER NAME PH6 0e)Ems¢ SO- (YY- 0) STREET ADDRESS ClT ZD' FAX , GATE L/ C SZ 1 1 CONTACT NAME /"' To 573 PHONE S/O- 3O - 7 Z E.ALL[[. STREET ADDRESS CITY, STATE, ZIP FAX ❑ OwNER ❑ OWNER.BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTRACTORAGQ+T ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONC. NAME r �LEc- Iti L'CENSE NUMBER L'CENSE TYPE I BUS. LIC d Z '11 t5 m Pu. lL Y70/3 Z COMPANY NAME_ //E-MAIL �t �A"\ FAX , 7�Q r'C?NAN�p b ✓A LGC CGK%QIC. •�Y�-OZY� STREET ADDRESS CTrY ATE•IIP -3 Z ,Qfk4F9-CIr/-��cL �Q. Sc=h oAu i gYS 3-S PHONE '3 -7YS-9,91 ARCHTCr/ENGINEER NAME LICENSE NUMBER BUS. LC 9 COMPANY NAME E -MAH. FAX STREET ADDRESS CITY. ST ATE, ZIP I PHONE DESCAIPTiON OF WOAX P(-Sw C 2,0 j2&r- 1 72L tZp-6: 'PL� EXE TNG USE PROPOSED USE CONSTR TYPE iSTORIES USE TYPE OCC SQ -FT. VALUATION (S) EtCSTG NEW FLOOR DEMO TOTAL AREA ARTA AREA NET. c - BATHROOM KTTCHEV D REMODELARFA REMODEL AREA - ODELAREA PORCH AREA OELTC AREA TOTAL ORCHAREA GARAG'c AAEA: DETACH Lj A TACH p DWELLING UM: ASECOND UNIT YES SECOND STORY OYES BMGADDEDr C]110 ADDITION' ❑NO PRE -APP' ,ON ❑YES EYES, PROVIDE CDPY OF IS THE BLDG AN ❑YES RECEIVED TOTAL VALUATION: P GAPPLd ❑NO PW1NIN°APPROVALLETTFA EICHLER HOME'. ❑NO ZZZ) By my signatubelow, I certify m each of the following: I am the propeml owner or authorized agent to act on the prppery f. owner's behalf. I have lead this signature, application and the information I have provj ,d is cerrecL I have mad the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and smte laws mlatv:g m il�d(in onsuucdan. I authorize representatives of Cuperino to mw the above -identified property for inspection purposes. C Signature of Apolicant/AgencDat<: Z—' SUPPLEb[ENTAL NFORLNLATION REQUIRED PtA.'r CHECK TYPE ROUTLNGSLIP Ltin.omG New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building OVER-THE-COUNTER /-<1 PLAN REvTZW permit for new building. ❑ EXPRESS P""MC PUN REvmw Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STXNDARD ❑ PUBLIC WORKS _ form if any Hazardous Materials are being used as part of this project. ❑ f.ULGE ❑ FERE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to 1:1 El submittal of Building Permit application. MAJOR sam'ARYSEWrz Dtsratcr ❑* ENVDLOhiMENTAL BF.ALTH BldgApp_2011.doc revised 06/21/11 7 c(.,C5.