12030038CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR CONTRACTOR. pQ D PERMIT NO: 12030038
OWNER'SNAhIE: HOADLEYLEON W TRUSTEE&ET AL jrne_SQ ll -ay DATE ISSUED: 03/08/20(2
OWNER'S PHONE: PHONENO:
LICENSED CONTRACTORS DECLARATION
License Class
T Lie.0 riy
Crnumcror Date -3/ , /Z
hereby affirm that 1 am licensed under the prurisions of Chapter 9
(commencing with Section 71100) of Division 3 of the Business & Professions
Code and that my license is in full force acid effect.
hereby affirm under penalty of perjury one of the following two declarations:
(have and will maintain a certificate of consent to self -insure fit Worker's
Compensation. as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this penult is issued.
1 have :rod will maintain Worker's Compensation Insurmtce, as provided for by
Section 3700 of the Labor Code, for die perfonnaee of die work for which this
perink is issued.
APPLICANT CERTIFICATION
I certify that 1 have rend this application and state that the above informationis
correct. 1 agree to comply with all city and county ordinances mid state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon We above mentioned property for inspection purposes. (Nle) agree to save
i indemnify and keep harmless die City of Cupertino against liabilities, judgments.
costs, mid expenses which may accrue against said'City in consequence of the
grinning of this permit. Additionally, the applicant understands and will comply
With all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
I /�/
A.Signat Date :1 (p/ry
13 OAVNER-BUILDER DECLARATION
hereby affirm that 1 am exempt from the Contractor's License Law for one of
(lie following two reasons:
I. as owner of (he property, or my employees With Wages as their sole conipensatim,
i Will do the Work, and the structure is not intended or offered for sale (Sec.7044,
iBusiness & Professions Code)
L as owner of the propeny,ll on
aexclusively contracting With licensed contractors to
construct the project (Sec.7044. Business & Professions Code).
1 hereby' affirm under penalty of perjury one of the following three
declaralions:
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 pennit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 ofthe tabor Code, for die perfomwnce of the Work for which this
pemhit is issued.
I certify that in the performance 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 Worker's
Compensation laws of California. If, rider making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
forthwith comply With such provisions or dais penink shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that I have read this application mid state that the above information is
correct. I agree to comply with all city and county ordinances mid 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 Cit• of Cupertino against liabilities, judgments,
costs. and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
With NI non -point source regulations per the Cupertino Municipal Code, Section
19.18.
Date
BUILDING PERMIT INFO: BLDG C ELECT r PLUMB rt
MECH C RESIDENTIAL r COMMERCIAL t'
JOB DESCRIPTION: REMOVE EXISTING TUB, INSTALL DEDICATED 15AMP
GFCI
OUTLET, INSTALL NEW WALE -IN BATH TUB
Sq. F( Floor Area: I Valuation: $1 1500
APN Number: 34253009.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
l80 DA 'S FROM L ST CALLED INSPECTION.
Issued bv: � L Date:
RE -ROOFS:
All roofs shall to inspected prior m any roofing material being installed. If a roof is
installed without first obtainine an inspection, I a__rce to remove all new materials for
inspection.
Signature ofAppliamt: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safely Code. Sections 25505, 25533, and 25534. 1 will maintain
complianee with the Cupertino Municipal Code. Chapter 9.12 and the Health
Safety Code, Section 25532(a) should I store or handle Hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
conbuninants as defined by the Bay Area Air Quality. Management District I will
mainta(u compliance with dre Cupertino Municipal Code, Chapter 9.12 and the
Hrdth & Safety Code. Sections 25505. 25533, and 25534.
Ow o utU zed e'en , /
Date:'
(hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Cir C.)
Lender's Name
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
�®�ggp� CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
JAFDD:R::E:SS:
23500 Cristo Rey Drive
DATE: 03/0812012
REVIEWED BY:
:Mecb. Penoithee
APN:
BP#:
"VALUATION:
1$11,500
"PERMIT, TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Elec. Inyr. pea..
PENTAMATION 1REAP10
PERMIT TYPE:
WORK
Remove existinq tub install dedicated 15 amp GFCI outlet install new walk-in bath tub.
SCOPE
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public IVorks, Fire, Sanitaly Seiner District, School
District, etc). Thaw fees are based on the prelininan, information available and are only an estinurte. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution I1-053 Elf 7/1/11)
Meeh Plan Che,k
Plumb. Plan Check 0.0 1 hrs $0.00
Elec. Plan Check 1 0.0 1 hrs $0.00
:Mecb. Penoithee
Plumb. Permit Fee: IPPERAHT
I Elec. Permit Fee: /EPERAnT
Or6v: ,(fe- b. Lip.
Other Plumb Insp. 0.0 hrs $44.00
Other Elec. Insp. 0.0 hrs $44.00
tf,b Imp. Fee-
P/mnl. /nrp. Fer:
Elec. Inyr. pea..
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public IVorks, Fire, Sanitaly Seiner District, School
District, etc). Thaw fees are based on the prelininan, information available and are only an estinurte. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution I1-053 Elf 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
1 #
$44.00
Electrical
IBREAfRECEP Recep/Switch/Outlets
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
F 1-1 #
$9.00
Plumbing
IBPFIATURE Fixture or Trap
Permit Fee:
$0.00
Supp[. Insp. FeeQ Reg. 0 OT
0,0
[ -its -
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$88.00
Construction Trrc:
Administrative Fee: IdDAnN
$41.00
0
Work Without Permit? 0 Yes E) No
$0.00
Advanced Planning Fee:
$0.00
Selecta Non -Residential
Building or Structure
0
Travel Documentation Fee: ITRA t DOC
$44.00
Strong Motion Fee: IBSEISHICR
$1.15
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$175.15
$53.001
TOTAL FEE:
$228.15
Revised: 1/19/2012
8 ITEMS OF 8
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 34253009.00
DATE ISSUED.......: 03/08/2012
RECEIPT #.........: BS000016221
REFERENCE ID # ...: 12030038
SITE ADDRESS .....: 23500 CRISTO REY DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
228.15
---------------
228.15
VOICE ID DESCRIPTION
-------- ----------------------------
304 ROUGH ELECTRICAL
512 FINAL HANDI-CAP
REFERENCE NUMBER
--------------------
#6778
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
OWNER ............:
HOADLEY
LEON
W TRUSTEE
& ET AL•
ADDRESS ..........:
23500 CRISTO
REY DR
CITY/STATE/ZIP ...:
CUPERTINO,
CA 95014
RECEIVED FROM ....:
QUALITY
LIFE
PRODUC
CONTRACTOR .......:
TBD - TO
BE
DETERMINED
LIC #
00096
COMPANY ..........:
TBD - TO
BE
DETERMINED
ADDRESS ..........:
CITY/STATE/ZIP ....
,
TELEPHONE ........:
FEE ID
UNIT QUANTITY
AMOUNT
PD -TO -DT
THIS REC NEW
BAL
----------
-ADMIN
------------- ----------
HOURS 1.00
----------
41.00
----------
0.00
----------
41.00
----------
0.00
1BCBSC
VALUATION 11,500.00
1.00
0.00
1.00
0.00
1BPFIXTURE
NO OF FIXTURE 1.00
9.00
0.00
9.00
0.00
1BREMRECEP
NO. OUTLETS 1.00
44.00
0.00
44.00
0.00
1BSEISMICR
VALUATION 11,500.00
1.15
0.00
1.15
0.00
IEPERMITFE
FLAT RATE 1.00
44.00
0.00
44.00
0.00
1PPERMITFE
FLAT RATE 1.00
44.00
0.00
44.00
0.00
1TRAVDOC
FLAT RATE 1.00
44.00
0.00
44.00
0.00
TOTAL PERMIT
----------
228.15
----------
0.00
----------
228.15
----------
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
228.15
---------------
228.15
VOICE ID DESCRIPTION
-------- ----------------------------
304 ROUGH ELECTRICAL
512 FINAL HANDI-CAP
REFERENCE NUMBER
--------------------
#6778
VOICE ID DESCRIPTION
-------- ----------------------------
505 FINAL ELECTRICAL
1191 LTJ
CUPERTINO
F-1 NFW CONSTRI[r
iW3O Jae
CONSTRUCTION PERMIT APPLICATION
COIvINIUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(4018) 777-3228 • FAX (408) 777-3333 • buildinD(a�cuoerdno oro
8)
TfIN 1 e ilmm�nr �n r rro �ri�nr r r. f1 1
PROIECT ADDRESS v AFN# V 1,••/Vy
OWNER NAME J /'t�� G(
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PHONE �. J
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STREET ADDY
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MY FATE. ZIP FAX
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CONTACT NAME ^ /
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STREETADDRESS
F v
CITY,STATE ZIP
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑CONTPACTORAGENT ❑ ARCEETECT OENGLNEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR N
LICENSE NUMBEPq
LICEN TYPE
BUB. LIC #
C/
U
COh1PANY NAME EMAIL
FAX
6-a13
STREET ADDRESS pry. SC TE ZIP
,5
Xr
��33
ARCHTLECT/ENOINEER NAME LICENSE NUb ER
BUS. tic'
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY. STATE, ZIP
I PHONE
DESCRIPTION OF WORK - _
Ve
&17f Ovrlf
1/M s65) rone e % 4eifE;`1 Dir/
EXISTING us,PROPOSED USE CONSTILTYIE 'STORIES
33
USE
TYPE
I OCC I
SQFr.
VALUATION ON (S)
Exorro
AREA
NEW FIAOR
AREA
DEMO
AREA
TOTAL
NET AREA
23
• V�3
.
BATHROOM KIiCFFitTTf OTHER
REMODELAREA REMODELAREA REMODEL AREA
I
I
PORCH AREA DECKARFA TOTALDECK/PORCHAREA GARAGEA DETACH
❑ ATTACH
No wELLWG UNITS:IS
A SECOND UNIT YES
SECOND STORY ❑YES
LIMCADDED? ONO
ADDR'IONI' ONO
PRE.APPLICATION OYES IF YES, PROVIDE COPY OF
ANNDl
PLGAPPL' ONO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑YES
EICHLERHONIE? ❑NO
RECEIVED
C,
TOTAL VALUATION:
// SoG
By my signature below,[ certify to each of the following: I am the pronerty owner or authorized a¢rnt m ac[ on the Frppertyowner's behalf. •i have read tails
epp(icati¢n and the informatio¢ f ha vided is correcL I have read the Description of Work and verify it is accurate. I agree W comply with all applicable local
ordinances and'sta[e laws relating 'Iding c "cti authorize representatives of Cupertino to rn[er the abov�7e-i/d�nGdy/ed property for itupttaon purposes.
f/
Signature, of ApplicandAgn' Date:
SUPPL I ALINFORIVLATIONREQUERED
PLA.NCFacXTYPE
ROUTING SLIP
_ New SFD or Multifamily dwellings: Apply for demolition permit for
2 OVER-THE-COUNTER
❑
existing building(s). Demolition permit is required prior to issuance of building
BOD.DiNG PLAN REVIEW
permit for new building.
❑ EXPRESS
❑ PLANYLVG PLAN REVIEW
mmercial Bldgs: Provide a completed Hazardous Materials Disclosure
T
❑ 3TAxoARD
❑ PUBLIC WORKS
if any Hazardous Materials are being used as part Of this project
❑ URGE
❑ FD1E DSPC
_ Copy of Planning Approval Letier or Meeting with Planning prior to
submittal of Building Permit application.
❑ MA.roR
❑
SANITARY SEWEA DISTRICT
❑ ENYERO" E.YTAL BEAT TB.
Bldg ipp_2011.doc revised 06/2!/11