13010079CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR #514y'`
CONTRACTOR: MISSION VALLEY
PERMIT NO: 13010079
ELECTRIC INC
OWNER'S NAME: SUSAN STANLEY TRUSTEE
PO BOX 3332
DATE ISSUED: 01/15/2013
OWNER'S PHONE:. 6509440100.
FREMONT, CA 94539
PHONE NO: (510) 745-8847
13 LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL EI
License Class G w Lic. # Z d '� Z_
INSTALL 6 (N) LED LIGHTS IN LIVING ROOM & 4 (N)
LED LIGHTS IN OFFICEBDRM AREA (10 TOTAL LIGHT
Contractor t 5-57o,3 V I — 1
FIXTURES). INSTALL 1 (N) OUTLET RECEPTACLE IN
I hereby affirm that I am licensed u4cr the provisions of Chapter 9
(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
Sq. Ft Floor Area:
Valuation: $5000
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
APN Number: 34253342532f3.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I 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 state laws relating
WITHIN 180 DAYS O T 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 FR A ALLED 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
Iss d Date: l l
granting of this permit. Additionally, the applicant understands and will comply
with all non -point sour guI tions per a Cupertino Municipal Code, Section
9.18.
Signature DDe ( '5t 3
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.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that.I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 or offered for sale (Sec.7044,
Business. &:Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Se6:7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & 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 I
performance of the work for which this permit is issued.
will maintain compliance with the Cu tino Muni ipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sec 'on 55 , 25533, nd 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: ate:
permit is issued.
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 Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION 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 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
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
�9T.J9t,,
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION r1
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 `� V
(408) 777-3228 • FAX (408) 777-3333 - building5cuoetno.org
x9 MEP
misc
❑PLUMBING ❑MECHANICAL NELEC=CAL ❑MISCELLANEOUS
PROJECT ADDRESS
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STREET ADDRESS
CITY, STATE, ZIP
FAX
CONTACT NAME
PHONE E-MAIL
STREET ADDRESS
CTIY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER
❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CO OR NAME
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LICENSE NUMBER LICENSE TYPE
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX
BUILDING: ❑ COMMERCIAL
❑ MULTI-FAMMY
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK C�
S i A- I j� LEj H7 57 LI
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TOTAL VALUATION:
IVED BY.
By my signature below, I c rtify to each of the following: I am the property owner or authorized ag-dn-ro—Efon the property o alf. I have read this
application and the information I havepr Id d is correct. I h e read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating b construction. I thorize representative of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: r Date: - $ —
UPPLEMENTAL INFORMATION QUIRED
OFFICE USE ONLY
❑ OVER-THE-COUNTER
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❑ EXPRESS
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MEPVzzscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
im,ADDRESS:
23500 CRISTO REY DR # 514K-&
DATE: 01/15/2013
REVIEWED BY: MELISSA
UNITS
APN: 34253213
BP#:
`VALUATION: 1$5,000
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Multi -Family Dwelling
USE:
Buildina is
1 >3 Stories ® Yes ® No
PENTAMATION 1 REAP11
PERMIT TYPE:
ORK
INSTALL 6 N LED LIGHTS IN LIVING ROOM & 4 N LED LIGHTS IN OFFICE/BDRM AREA 10
OPE I
F
TOTAL LIGHT FIXTURES). INSTALL 1 (N) OUTLET RECEPTACLE IN OFFICE/BDRM & 1 (N) p
APPLIANCE / EQUIP TYPE
FEE ID
11himb. Plan Checl
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Fixtures, Lighting
1BREMFIXT
Other Elec. Insp. 0.0 hrs $45.00
10
#
$67
Recep/Switch/Outlets
1BREMRECEP
Suppl. Insp Fee
2
#
$45
PME Unit Fee:
$112.00
PME Permit Fee:
$45.00
Constt fiction Tax.
Administrative Fee: 1ADMIN
$42.00
Work Without Permit? ® Yes 0 No
$0.00
TOTALS:
F
Travel Documentation Feer ITPA VD0C
$112.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc-). These fees are based on the Dreliminary information available and are onlv an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resolulion 11-033 Eff.' 7/1%72)
Mech-Plan Check,
11himb. Plan Checl
Elec. Plan Check 0.0 hrs $0.00
11?ech. f'err„ir t'
Plumb. Permit P't'e:
Elec. Permit Fee: IEPERMIT
Chher Meeh. lrsj _
Other Plumb Insp.
Other Elec. Insp. 0.0 hrs $45.00
I tech_ Insp. Fee:
Phrnrl, buss. Fee:
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc-). These fees are based on the Dreliminary information available and are onlv an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resolulion 11-033 Eff.' 7/1%72)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
S'uPpL PC.Fee
PME Plan Check:
$0.00
Perinit Fee:
Suppl. Insp Fee
PME Unit Fee:
$112.00
PME Permit Fee:
$45.00
Constt fiction Tax.
Administrative Fee: 1ADMIN
$42.00
Work Without Permit? ® Yes 0 No
$0.00
,1dv,wwed P1C11717in(1? Fees:
Travel Documentation Feer ITPA VD0C
$45.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$245.50
$0.00 TOTAL FEE:
$245.50
0 Revised: 10/01/2012
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
cup�runo, CA
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS:Z 507b 67 -I45 -1-b l�-c
OWNER'S NAME:F-0 Zv
' PERMIT #
PHONE # �� - 30 - g Z Z
GENERAL CONTRACTOR: ftl tGt
[,c BUSINESS LICENSE #
ADDRESS:`3
CITY/ZIPCODE: T- S
*Our municipal code requires all businesses working in the city to nave a t.ay or t,uperrinu uusill-35 LCCIIJC.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL BCONT CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. e
I am not using any subcontractors: ' +
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
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
Owner / Contractor Signature
Date