12100031CITY OF CUPERTINO 13UILDING PERMIT
BUILDINGADDRESS: 23500 CRISTO REY DR UNIT 218E CON`fRACI'OR: BAY AREA ENTERPRISE PERMIT NO: 12100031
OWNER'S NAME: YATES MARGERY A TRUSTEE R I E.I' AL 21 10MANGIN WAY DATE ISSUED: 10/042012
OW'NER'S PRONE: 6505371523 SAN JOSE, CA 95148 PHONE NO: (408(238-5043
❑ LICE�SED C0N`rRAC`f0R'S DECLARATION
License Class 5 Lie. # 1;;11 q
Contractor Dare 0
1 hereby affirm ih m i e under the provisions of Chapter 9
(commencing will,
Sectio Otp of Division 3 of the Business S Professions
Cade it that n 'license i5 in full force and effect.
I hereby affirm under penalty of perjury one of the following 1w 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.
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
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application mid sone that the above information is
correct. I agree to comply with all city and county ordinances and slate laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may me against said City in consequence of the
granting of this permit. Additi n: ly, the app lict-1 understands mid will comply
will all non -point sour Yr ai is per the Cupertino Municipal Code, Section
9.18.
61 jo�Q Loly
Signature Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am excnhpt from the Contractor's License Laefor one of
the Following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, mid 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
construct the project (Sec.7044, Business R Professions Code).
hereby affirm under penalty of perjury one of the following three
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.
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
pennit is issued.
I certify that in the perfommnce of die work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the W'orker's
Compensation Imus of California. If, after making this certificate of exemption, I
become subject to the W'orker's Compensation provisions of the Labor Code, 1 must
forthwith comply with such provisions or this permit shall be deenhed revoked.
APPLICANT CF.RTI FI CATION
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinmwes mid state laws relating
to building construction, and hereby authorize representatives of this city to neer
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabil ities, judgments,
costs, and expenses which may acerae 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
9.18.
Date
BUILDING PERMIT INFO: BLDG r ELECT 1- PLUMB r1
N1ECI1 I✓ RESIDENTIAL rJ COMMERCIAL (J
JOB DESCRIPTION: CHANGE SHOWER TILE AND SHOWER VALVE
Sq. Ft Fluor Area: I Valuation: $2000
ANN Number: 34253082.00 1 OccupancyType:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: �EANTG� Date: le -
RE -ROOFS:
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.
Signature of Applicant: Date:
ALI, 11001; COVERINGS T'0 BE CLASS "A" OR BE TER
IIA%ARDOUS NIATERIAIS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California I Iealth S Surety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health S
Safety Code. Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance Wittrf/i he Cupertino Municipal Code, Chapter 9.12 and the
Health S Safe4\Code. S lions 25505. 25533, and 25534.
Date: ply
CONST'RUC1'ION LENDING AGENCY
I hereby afinn that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Leader's
ARC111TECI"S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinc0cuoerino.oro
lZlv�0�l
IXIPLUMBING 7MECHANICAL 7ELECIRICAL 7NUSCELLANEOUS
MEP -
MISC
PR07SrADDFMS ' N9 :IAA, 2 �3 b82
`%S-
OWNER NAME ]I1L Fr%rUIH (
PHONE�
S3 r/ ( 23
E-MAIL.
ST=ADDRESS CITY, STATE, ZIP 'V
73cov Cr�S'><a -R��, ��• Ho c11'
FAX
CDNTACT NAME G re < t
PHONE _z 3fr-soya
Z!'ArL • r^ec�d -fie •('• .�
I •S � �r
sTREErADDAESS
Z Il tl N o V�,
STAr4 ffi
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNc�t AGET ice' CONT PACTOR ❑CO),rTRACroR AGENT ❑ ARCFTECT ❑ ENuaT.Zi. ❑ DEV --OPER ❑ TENANT
CONTRACTOR NAME s LICENSE NUM 7 -I� IJCWF
BUS. IJCR
CDMPANY NAME r �h/--r- - • .e c L (Gm
'h
7 r�Y�
FAX
TR
SEET ADDRESS „') I I U d .I �n , I S e A 9 S U
PHONE 4fo"
b
A-
ARCHITECr/FNGE-RR NAME I LICENSE NUMBER
BUS. LIC p
COMPANY NAME
E-MAB-
FAX
SITLEFT ADDRESS
CTiY, STATE, 7LP
PHONE
USE OF FD m DUPLEX ❑ MULT FA Y I PROIECr IN WIDtAND ❑ YFS I
BUILDING: ❑CONAffR URBANINTZRFACEAREA NO
PROJECT IN ❑YES
FLOOD ZONE O
IS THE BLDG AN ❑YES
EICH1 HOMEI NO
DESCRIPTION OF WORK '
TOTAL VALUATION: /` V i " �
RECEIVED BY:
By my signature below, I certify to each of the following: I am ( c property owner or authorized agent ;o act on the property owner's behalf. I have rend this
application and the imorrnadon I have providedis <o. c: t hav :zed the Description of Work and vcti-ry it is accurate. I agree W comply with all applicable local
ordinances and s -a c laws relating to building onI an, or.-- _ msentadves of Cupertino to enter the above -id tSe�T properjyo specdon puh%,Joses.
Signature of ApplicanUAgenO �' Da;e: O
SUPPLE \ I'AL —O TION REQUIRED
OFFICE use ONLY
u
U
Z
OVER-THE-COUNTER
EXPRESS
❑ STANDARD
❑ I-ARCE
❑ NIAIOR
MPPMucApp_20/1.doc revsed 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
JAFADDRESS:
23500 Cristo Rey
DATE: 10/04/2012
REVIEWED BY: Sean
UNITS
APN:
BPtt:
'VALUATION:
$2,000
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex
USE:
$10
PENTAMATION 1RPFIX
PERMIT TYPE:
WORK
Chan a shower tile and shower valve.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
I Elec. Permit Fee:
Fixture or Trap
1BPFIXTURE
Otter Elco Insp. Li I
1
#
$10
Perini! Fee:
SuPpl. Insp Fee
PME Unit Fee:
$10.00
PME Permit Fee:
$45.00
r.On.Sli'liction Tax:
Administrative Fee: IdDMIN
$42.00
Work Without Permit? 0 Yes Q No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$10.00
Strong Motion Fee: IBSEISMICR
A'OTF: This ewinrate does not include jeer due to other Departments (i.e. Planting, Public {Yorks, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the prelinzinan information available and are atilt, an estinmte. Contact tire Dept for addn'I info.
FEE ITEMS (Fee Resolution 11-053 E/f 711/1!1
Alech. Plan Check
Plumb. Plan Check 0.0 1 hrs $0.00
rice. P/at Check
,Nech. Pencil Fee:
Plumb. Permit Fee: /PPER wT
I Elec. Permit Fee:
Other Alech. Insp.
Other Plumb Insp. 0.0 hrs L$45.00
Otter Elco Insp. Li I
,I/ech. htep. Fee:
Plumb. hisp. Gee:
Elec. Lisp. Fee:
A'OTF: This ewinrate does not include jeer due to other Departments (i.e. Planting, Public {Yorks, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the prelinzinan information available and are atilt, an estinmte. Contact tire Dept for addn'I info.
FEE ITEMS (Fee Resolution 11-053 E/f 711/1!1
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
suppl. PC Fee
PME Plan Check:
$0.00
Perini! Fee:
SuPpl. Insp Fee
PME Unit Fee:
$10.00
PME Permit Fee:
$45.00
r.On.Sli'liction Tax:
Administrative Fee: IdDMIN
$42.00
Work Without Permit? 0 Yes Q No
$0.00
Advanced Planning Fear:
Travel Documentation Fee: ITRA VDOC
$45.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Blde Sids Commission Pee: IBCBSC
$1.00
SUBTOTALS:
$143.50
$0.00
TOTAL FEE:
$143.50
Revised: 10/01/2012