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15120109N CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 406F CONTRACTOR: BAY AREA ENTERPRISE PERMIT NO: 15120109 OWNER'S NAME: LARSON CARL V TRUSTEE & ET AL 2110 MANGIN WAY DATE ISSUED: 12/14/2015 OWNER'S PHONE: 6505371523 SAN JOSE, CA 95148 PHONE NO: (408)238-5043 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lie. # � J 1 UNIT 404F & 406F - COMBINE UNITS (OTHER REMODEL AREA 50 S.F.)& ADD 13 RECESSED LIGHTS IN BEDROOM, Contractor A- Date `\ �� ��� LIVING RM & HALL I hereby affirm that I am licensed under 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 ompensation, 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 Sq. Ft Floor Area: Valuation: $12000 Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 34253173;00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction, and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property Pr inspection purposes. (We) agree to save indemnify and keep harmlessthe C y of Cupertino against liabilities, judgments, 180 DAYS FR C ED INSPECTION. costs, and expenses which may acc a against said City in consequence of the of this itionall �� granting permit, , the applicant understands and will comply a with all non -point s urc egulation per the Cupertino Municipal Code, Section 9.18, R OOFS: Signature Date it (� 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. ❑ OW ER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE ASS "A" OR BETTER will do the work, and the structure is not intended or offered for sale (See.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERL DISCLOSURE construct the project (Sec.7044, Business &Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the I hereby affirm under penalty of perjury one of the following three California Health &Safety Code, Section 25505, 25533, and 25534. I will maintain compliance with the Cupertino unicipai Code, Chapter 9.12 and the declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Health & Safety Code, Section 25532(a quld I store or handle hazardous material. Additionally, should I use e u p ent or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the y r# Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the no Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Section 255 5, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. i 1 Owner or authorized agent: Date: i 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 CONSTRUi TIO LENDING AGENCY become subject to, the Worker's Compensation provisions of the Labor Code, I must 1 hereby affirm that there is a cons uctio 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 issu d (Se . 3097, Civ C.) Lender's Name i 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S 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 CONSTRUCTION IT APPLICATION— COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE s CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 5taiidingt?euDeriirly ora NEW CONSTRUCTION ❑ ADD££ION ,LIERATIQNt.IT' ❑ REVISION /DEFERRFn h r1RTI-MAT 73T7 PROIECTADDRESS , cn APN RG_S7w 5-_q - OWNER NAMEJ P r4MAIL il1 �r �►r'la 4 ?A a- 3 - �3"Z3 IA -e4 STREET ADDRESS o %j , • a44:3b bt •Gast' C T Z FAX CONTACT NAME - �jL-e ' S PHONE _ 23 $ �i�.3 E-MAIL -het 3� c o tly STREET Z {:Sb CITY, STATE, ZIP FAX -e S s 0 OWNER 0 OWNER -BUILDER 0 OWNER AGENT 0£ONTRACTOR © CONTRACTOR AGENT 0 ARCHITECT ❑ ENGINEER 0 DEVELOPER 0 TENANT CONTRACTOR NAME Fe LICE ZE NUMBER fry Riq LICENSE TYPE BUS. LIC s COi4IPANYNINAIE �. iVir•• G.. n��. _ EMAIL ... .. ._ -. 0Z FAXIn. r+MQle D STREET ADDRESS . CITY, STATE, ZIP PHO NE c 57 8 YQ - Z3 - �y ARCHITECT/ENGINEERHAME LICENSE NUMBER BUS. LIC n COMPANY NAME E .SIAIL FAX STREET ADDRESS CITY, STATE, ZIP .... - PHONE. DESCR12' N OF WORKn r o y �( �G OL^ till,�S h ®v � e �1 3 4&�eecsspee dt f S r'A s!pIger 044, va1Ye wo EX SING USE - PROP SED U CONSTA TYPE #.STORIES - - ....NEW USE TYPE OCC. SQ.Fr. VALUATION (S) EXISTO AREA FLOOR AREA -DEMO AREA TOTAL NETAREA BATHROOM `. REMODEIT, AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECi{/POR�AR"EA�GARLAGEAREA: -DETACH 0 ATTACH _ H DWELLING UNITS:. IS A SECOND UNIT DYES SECOND STORY DYES BEING ADDED? ONO ADDRION? ONO. PRE -APPLICATION DYES IF YES, PROVIDE COPY OF PLANNING ADPL 0 ONO PLANNING APPROVAL LETTER IS THE BLDG AN El YES 11-TIII&L VALUATION: EICHLER HOIVIE? o behalf. I hav read this By my signature below, I certify to each of the fill I am the propertyer or authorized agent to act on the pro�Ia application and the information I have provided is c ct. I ha - ead the Description of Work and verify it is accurate: o comply ivitll all applicable local ordinances and state taws relating to building con :tion. 1 a orize representatives of Cupertino to enter the above-ified property for inspection purposes. Signature of Applicant/Agent: :_, J 7- SUPPLEMENTf,L INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _ New SFT} or Multifamily dwellings: Apply for demolition permit for OVER-THE-COUNTER (] BumDtNG. PLAN REYtEw existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ rxPREss PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD E PuBmc wORKS form if any Hazardous Materials are being used as part of this project. LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR ❑ SANITARY SEWER nlsTRtcr submittal of Building Permit application. ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06121111 CITE' OF CUPERTINO FFF: 1F,CT1MAT(l12 — RTTTT "IXTt" nrArrert-%xT ADDRESS: 23500 CRISTO REY DR #406F DATE: 12/14/2015 REVIEWED BY: MELISSA APN: 342 53 173 BP#: *VALUATION: $12,000 PLAN CHECK TYPE:: 0*PERMIT TYPE: Building PermitFBuildina Alteration / Repair PRIMARY Multi -Family Dwelling is PENTAMATIONUSE: ries Q Yes E) No PERMIT TYPE. 1GENRES� WORK UNIT 404F & 406F -COMBINE UNITS OTHER REMODEL AREA 50 S.F. & ADD 13 RECESSED SCOPE LIGHTS IN BEDROOM, LIVING RM & HALL hrs i v i nis estimate aoes not inctuae fees aue to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). f FEE ITEMS (Fee Resolution 11-053 E '. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 =S. $431.00 Remodel, Other IREMRESOTH Permit Fee: $0.00 Suppl. Insp. Fee:(D Reg. 0 OT f 0,01 hrs $0.00 16 Electrical $72.00 IBREMFIAT Fixtures, Lighting PME Unit Fee: $0.00 PME Permit Fee: $48.00 Administrative Fee: )ADMIN $45.00 Work Without Permit? 0 Yes a No $0,00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure E 0 Travel Documentation Fee: ITRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $1.56 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS; $143.56 $503.00 TOTAL FEE: $646.56 Revised: 10/01/2015