12120028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23600 VIA ESPLENDOR CONTRACTOR:MISSION VALLEY PERMIT NO: 12120028
ELECTRIC INC
OWNER'S NAME: ROMAN CATHOLIC BISHOP OF SAN JOSE, PO BOX 3332 DATE ISSUED:12/06/2012
OWNER'S PHONE: 6509440100 FREMONT,CA 94539 PHONE NO:(510)745-88,17
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class —[d Lie. MECH r RESIDENTIAL r COMMERCIAL r
Contractor ate Z 6y z
I hereby a rm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL TWO(2)NEW 20 AMP CIRCUITS M KITCHEN AT
(commencing with Section 7000)of Division 3 of the Business&Professions HEALTH CARE FACILITY
Code and that my license is in full force and eff"L
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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1100
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:34254016.00 Occupancy Type:
APPLICANT CERTIFICATION
1 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 and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point s w ce regulati is per the Cupertino Municipal Code,Section ,yli
9.18. Issue
Date/. /
Z�
Signature Date
4-1 -Z_
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should 1 store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health 8 afety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I or authorize g int: , .
become subject to the Worker's Compensation provisions of the Labor Code,I must ate:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of vork's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and wanly ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accme against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
12- 1 2 007
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 A /�
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FROJECTADDRESSV t P e S
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OWNER NAME PHO E-MAIL
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CONTACTNAME PHONE ¢rte' E-MAIL
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STREETADDRESS QTY,STAT'$ZIP FAX
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DOWNER ❑ OWNER-OVIDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACIORAGFNT ❑ ARCHRECr ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICgNSENUMBEP. LICENSE TYPE BUS.UC a 3 3
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COMPANY NAA¢ E-MAIL FAX
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ARC,HTEC IENGINEFR NAME LICENSE NUMBER BUS.tic
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CTIY',STATE,ZIP PHONE
USE OF ❑ LDC ❑ MULTI-FAMILY PROJECT PJ WIDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YFS
B=. NG: COAAfERCW. IN
❑ NO FLOOD ZONE ❑NO EICHLER HOME! ❑NO
DESCRIPTION OF WORK
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TOTAL VALUATION: //ln,v'� RECEIVED BY: 7"
By my signatre below,I certify to each of the following: I sum the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have is correct I have read the Description of Work and verify it is accurate. I agree fo comply with all applicable local
ordinances and scam laws relating nstructioa I anthotize representatives of Cupenirc o enter the above-identifiedprope.:j for inspection po:poses.
Sign-nofApplicanVAgent Dat: 7– — 5; — Z
PLEV=AL WFORMATTON REQUIRED OFFICEUSEONLY
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❑ MAJOR
MEPMrsc4pp-2011.doc revised 06/21/11
q� J eq CITY OF CUPERTINO
V FEE ESTIMATOR-BUILDING DIVISION
ADDRESS:-2V609-edstTFe7Vr. DATE: 12/06/2012 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: $0
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION
USE: PERMIT TYPE: 1REAP7
WORK I install 2 new 20 amp circuits in kitchen at health care facility..
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Conductors 1BREMMISC 1 # $133
TOTALS: $133.00x,�,t
Alech. Plan Check Plumb.Plan Check Elec.Plan Check 0.0 hs $0.00
Mech. Persil Fee'• Plumb.Permit Fec•: Elec.Permit Fee: IEPERMIT
Other A1e,h.Insp. Other Plumb Insp. Li I Other Elea Insp. 0.0 hrs $45.00
Adeeh. Inst'.fee: Plumb. Insp.Fee: Eley.Insp. Fee.
NOTE:This estimate does not include fees due to other Departments(1.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District eta). These fees are based on the relimina in ormation available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS(Fee Resolution 11-053 ER' 7IMI FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $133.00
PME Permit Fee: $45.00
Construction Tax:
Administrative Fee: IADWN $42.00
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $45.00
Strong Motion Fee: $0.00 j Select an Administrative Item GI r
Blde Stds Commission Fee: $0 1
$265.00 $0.00 TOTAL,KR. 1 65.00
Revised: 10/01/2012