12080085CITY OF CUPERTINO BUILDING PERMIT
BUILDING. ADDRESS: 23500 CRISTO REE DR UNIT I IOD
CONTRACI'OR: MISSION VALLEY
PERMIT NO: 12080085
ELECI'RIC INC
OWNIiR'S NAJIE: EISENBERG EDD'II TRUSTER
1'0 BOX 3332
DATE ISSUED: 08/082012
ON'NE,R'SPIIONE: 6509440100
PREMO\T,CA 94539
PI IONF. NO: (510) 745.8847
❑ LICENSED CONTRACI'OR'S DECLARA'T'ION
r r r
BUILDING PERMIT INFO: 13LDC ELECT PLUMB
Ciccnsc Class _ .10 Lic. qy 0�3
r r r�
COMMERCIAL
tt55roi-+V
i11EC11 RESIDENTIAL
C. Itracmr I to
1 hereby mnlTinn That l am IicensrJ under the prorisiom of Chapter')
I by cbenring
JOB DESCRIPTION: REPLACE(2)EXIIAUST PANS, INSTALL (2) 1IEAT LAMPS,
with Section 701111) of Division 3 of the linsiness S Professions
INSTALL (7)RECESSED LIGHTS IN KITCI IrN, REPLACE ALL
(13)$WITCI'IE$ RECEPTACALES (23)
Code and that my license is in full force and effect.
hcrchy affirm under penalty of perjury one of The following oro 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
Sy. FI Ploor Area:
Valuation: $6000
Section 3700 of the Labor Code, for the performance of tl,e work for which this
permit is issued.
APN Number: 34253031.00 Occupancy Type:
API' LIC\NTCERTI FICATI ON
I certify that 1 have read this application and state that the above infom,ation is
correct. I agree to comply with all city and county ordinances mad suite lnvs relating
to building construction, and hereby authorize representatives of this city to enter
upon theabove memioned property for inspection purposes. (We) agree to save
PERMIT E 'IBES IF WORK ISNOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments.
costs, and expenses which may accrue against said City in consequence of the
NVITHIN DAYS OF PERMIT ISSUANCE OR
grunting orwispermit. Additionally, theappllcantllodcrstandsand will comply
180 DAY OM LAST CALLED INSPECTION.
with all non-point sou egulaticns per the Cupertino Municipal Code, Section
9.1 R.
_—�
-
hued b}': Dale:
Signature Dme_�(J r
V
❑ OWNER-BUILDER DECLARA'T'ION
RE: ROOFS:
I hereby affirm that I tan exempt Donn the Contrac or's License Law for one 0f
All roofs shall be inspected prior to my roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole comM1nsalion,
inspection.
will do the work and the structure is not intended or offered for sale (Sec.7044,
Business & Prolcssions Code)
Signature of Applicant: Date:
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sce.7044, Business C Professions Code).
ALI, ROOF COVERINGSTO BE CLASS "A" OR BETITH
I hereby affirm under penalty of perjury ane of the follmring three
declarations:
I have and will maintain a Cenilicate ofConsent to self-insure for Worker's
IL\%,UtDU11S dL\'1'I[R L\LS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California I Iealth .4 Safety Code, Sections 255115. 25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health S
Section 3700 of die Labor Code, for die performance of the work f'or which this
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
conlnminanls as defined by the Ray Area Air Qualily Management District 1 will
I certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cuperlino Municipal Cade, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Ilea lth & S• fen Code, Seglions 25505, 25.433• and 25534.
Cunnpensation laws ol'Cnlifornia. If, alter making this certificate ol'excmption,.l
�1:
become subject to the Worker's Compensation provisions of the Labor Code, I must
Ow'n g thorizrd a s
forthwith comply with such provisions or this permit shall he deemed revoked.
CONST'RIK-71ON LENDING AGENCY
,u'r1.1G.\� r cEaT'rP1C\TTON
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and count' ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Leader's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCI I I'I'ECI"S DECLARATION
all non-point source regulations per the Cupertino Municipal Code, Section
-
9.18.
9.18.
1 understand my plans shall be used aspublic records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
ICY//I FEE ESTIMATOR -BUILDING DIVISION
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 prelintimtrt, infonaation available and are only an estimate. Contact the Dept for melt'! info.
FEE ITEMS (Fee Res(jlution 1/ -053 Eff 7/1/11)
ADDRESS: 23500 Cristo Rey Dr.
Plumb. Plan Check
DATE: 0 810 8/2 01 2
REVIEWED Bl': gs
Plumb. Permit Fee:
APN:
6114:
'VALUATION:
$6,000
*PERM ITTVPE:
Building Permit
Elec. Insp. Fac:
PLAN CHECK TYPE: Addition
I'RIDWRI'
USE: SFDorDuplex'
PME Plan Check:
PENTAMATION
PERMITTYPE: 1RMAP
YORK
=
$137.00
Electrical
IBREMRECEP Recep/Switch/Outlets
SCOPE
Permit 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 prelintimtrt, infonaation available and are only an estimate. Contact the Dept for melt'! info.
FEE ITEMS (Fee Res(jlution 1/ -053 Eff 7/1/11)
Mech.. Plan Check 0.0 hrs $0.00
Plumb. Plan Check
Elec. Plan Check0.0 hrs $0.00
Mech. Permit Fee:' 1,tJPERMIT
Plumb. Permit Fee:
Elec. Permit Fee: lEPERhIIT
Other Mech. Insp. 1 0.0 firs $45.00
Other Plumh Insp.El
Other Elec. Insp. 0.0 hrs $45.00
,[loch. boli. Fee: �
Phuuh. btsp. Fee:
Elec. Insp. Fac:
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 prelintimtrt, infonaation available and are only an estimate. Contact the Dept for melt'! info.
FEE ITEMS (Fee Res(jlution 1/ -053 Eff 7/1/11)
FEE
QTY/FFE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$68.00
Mechanical
IhBREMINH Flood, Mech. Exhaust
'Sitppl. PC fee: (j) Reg. O O'1'
1 0.0
hrs
$0.00
PME Plan Check:
$0.00
=
$137.00
Electrical
IBREMRECEP Recep/Switch/Outlets
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME f ermit Fee:
$90.00
Consnttction Tae:
Administrative Fee: (ADMIN
$42.00
O
G)
Work Without Permit? O Yes (j) No
$0.00
Advanced Plannine Fee:
$0.00
Select a Non -Residential
Building or Structure
G
A.
Travel Documentation Fee: ITRA PDOC
$45.00
Stone Motion Fee: IBSEISMICR
$0.60
Select an Administrative Item
Blde Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$178.60
$205.00
TOTAL FEE:
$383.60
Revised: 07101/2012
C�UPERTINO
(
1 NEW comm -mi tf r)Nr
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 7773228 • FAX (408) 777-3333 • buildinG(dcuoeruno ora
M Anmmnm 51er rrn.,-tnuirr I-1
i2 i
--- --' VNVllvgL CC1tM11R
PROF=ADDRESS
Z X00 C2t5Ta � IAPtvx vrJl i �IL(� �✓
OWNER NAME
0 2J
PHONE
6so- 4Y —O lOp' E -MAB.
STREET ADDRESS
CrN. STATE ZIP
Ca 45or
I FAX
CONTACT NAME
PHONE E -MAR.
f C-1Zr0I
Sto -30 - Z2 Fe Pr D. is +o./✓nL
S71--MrADDRESS CN, fa ZiP
37Z iZt✓ �z��K 44 gY53�
FA.Y
`I daT--
s-io 7 Ys- -0
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECr DEYII.OPSR ❑ rENANr
CDNTRA TOR NAME LICENSE NUMBER
�S510 w E+—Fc%GL 3 [ Z
I LICENSE TYPE
G_ v
I BUS, UC 0
COMPANY NAME
I E-MAIL
FAX
-� io-7ys-dLYB"
ADDAE
O a 333 z
QTY Ara 7-P
I 7 0�i -
SONE
ARCFmrECT/PNGINEEL NAME LICENSE NUMBER
Bus. UC p
COMPANY NAME E-MAIL
FAY
STREET ADDRESS I C.7 -Y. SAT -F ZIP
I PHONE
DESCRD'Ii0 OF WORK
2E c we -z- I Ms rp z ir; L r PS
IN t r_ % 115 E Lllli i ILl t 13 Sw t /re S
E�(LSTII+G USE PROPOSED USE
COIN$/TI gE
I
15TH'
USE
I TYPE
V -1J
/
OCC
sQ.FT.I
VALUATiON(S)
H Tr
AREA 7,5Q
lGJr//
NEWFLOOR
ARE1 ��
DEMO
AAEA� YI
/1or�x
TOTAL
NET.ulE� 1�%/✓)
/ !��
BArHRooM ICiI'Cl@+
RIZ40DELAREA REMODEL. AREA RE?4,00MAREA
PORCH AREA DECKAREI
TOTALOECR/PORCHAREA GARAGEAREA:DETACH
❑ATrACH
p DWcLLnIG UNri$:
I5A5ECONDUNTr ❑YES SECOND STORY []YES
3EINGADDED7 ONO ADOMON: - ONO
PRE-APPUCAnDN OYES IF YES. PROVIDE COPY OF IS TEE BLDC AN Ors
PLANNNG APPLi ONO PLA.YNING APPROVAL LE -rt -:R I EICHLEA ROME' ONO
RECENED BY:
-
?pTAL VALUA7?ON:
-
60�D,
By my sig¢amre below, I ceriry, m each of die following. 1 am the property owner or authorized agent to act on the orpperry owner's behalf. l have read itis
application and the= I have d is carrecL I ve rvd the Descripron of Work and vedry it is accurate. f agree to comply with all applicable local
ordinances and sate Laws relatin 'lding construction. utbo= mP= es of CUPert.'nO m enter the abo`vve-idm6 ied pmpe,Y for bssnecdon pLuposes.
Sigaatute of AppGeant/Age¢c Date: U
SUPPLEMEN AL INFORIMA"T"iON uaED
PLAN CHECK TYPE
ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is remtired prior to issuance of building
OVER THEE CoovrER
❑ BUILDING PLAY REVIEW
.
permit far new building.
❑ EXPRESS
❑
PLA.YYLYG PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑
Form if any Hazardous Materials are being used as partof this project.
Fmn.JC WORKS
❑ LARGE
❑ ME DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
Submittal of Building Permit application.
CI MAJOR
Cl "MTARY SEWER DISTRICT
❑' ENVOLOSHENT.LL HEALTH
B1dgApp_2011.doc revised 06/21/11