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12080235CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRIS9'O REY DR OWNER'S NAME: Till- FORUM RANCHO SAN ANTONIO OWNER'S I'DOCE: 6505371041 ❑ I:ICIiNSLD CONfRACfOK'S DE'CLAR:\TION License Class c^3. G_ Lie. A5� �y Contractor&9MLAMIiCfG/MI� Date 5c-g*Z^ �( 1 hereby affirm Thal 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 fall force and effect. 1 hereby alTirnr under penalty of perjury one of the following ten declarations I have and will maintain u certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of work for which [his permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the pert ar none of die work for which this permit is issued. AITLI CANT CI, WIT FICATION I certify that 1 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, mid hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep hamiless the City ol'Cuper ino against liabilitics,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 all non -pint source regulations per the Cupertino Municipal Code, Section 9.18. 1 A i , DalcTtr-aA2-e z ❑ — OWNER -BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Lmv for one of the following Ivo reasons: I, as owner of the property, or my employees with wages as their sole compensation, trill 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 contactors to construct the project(Sce.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the fnllnwing three 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 Section 3700 of the Labor Code,. for the performance of the work for which this permit is issued. I certify that in the performance of die work for which this permit is issued. I shall not ennploy any person in any amnncr so as to become subject to the Worker's Compensation laws of California. II', after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. .\I'I'LIC.\N'I' CFK'1'IFICA'1'ION I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state Imus 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, 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 all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date CONTRACI'OR: GREAT AMERICAN PERMIT NO: 12080235 PLUMBING CO INC P 0 ISO\ 26942 DATE ISSUED: 081222012 SAN JOSE, CA 95159 PHONE NO: (408)279-1515 BUILDINC PERMIT INFO: BLDG 1- ELECT r PLUMB r NIECII r RESIDENTIAL U. COMMERCIAL r JOB DESCRI PTION: REPLACE TI 11: ['-TRAP ON FLOOR DRAIN IN POOL E•QUI I'MENT Sq. Ft Floor Area: I Valuation: $1600 AI'N Number: 34254999.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: —/41✓ 174L/G1 /Date: til: ROOFS: All roofs shall be inspected prior many roofing material being installed If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS'TO IIF, CLASS "A" OR RE ITER IIA%ARDOUS NIATF.RIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Il ca It It & Safer Code, Sections 25505. 25533, and 25534. 1 will main In in compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth & Safety Code. Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants its defined by the Bay Area Air Quality Nla angelical District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 unit the Ilealth & Safety Code. Sections 25505. 25533. and 25534. or Dale: 75^ z r� CO,NSTRUCI'ION LENDING AGENCY I hereby of firm fad there is a construction lending agency far die performance of murk's for which this permit is issued (Sec. 3097, Civ C.) Leader's Name Lender's ARCIIITFCT'S DECLARA'T'ION I understand my plans shall be used as public records. I Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR -BUILDING DIVISION kl[APN: DRESS: 23500 Cristo Rey Dr DATE: 08/22/2012 REVIEWED BY: Sean UNITS BP FEES BP#: 'l'AI.U,lT10N: $1,600 "PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building $10 PENTAMATION 1CPFIX PERI111TTYPE: i WORK Re lace the P -trap on floor drain in pool equipment room. SCOPE APPLIANCE/ EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES r1ec. Penna ree: Fixture or Trap 1BPFIXTURE Other Elec. Lisp. 1 # $10 Permit Fee: .4uppl. Insp I'ee PME Unit Fee: $10.00 PME Permit Fee: $45.00 Consimcdon Tax: Administrative Fee: IADAIhv $42:00 Work Without Permit? O Yes Q No $0.00 IOTA LS: i Travel Documentation Fee: ITRAI DOC $10.00 Strong Motion Fee IRSEISAIICO NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public n'ort:.a, hire, Sanitary Server District, 3c000t D' TI bused on the reinari information available and are only art esdinale. Contact the Dept or aildn'l info. lAtrct. etc.). test. el4 are lim FEE ITEMS (Fee csolution 11-053 Elf 7/1/11) Mech. Plan Check Plumb. Plan Check 0.0 1 hrs $0.00 Flee. Plan Check Alech. Permit Fee: Plumb. Permit Fee: IPPERAHT r1ec. Penna ree: Other Alech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec. Lisp. ,blech. hip. Fee: Plumb. hop. Fee' Fice. Insp. Fec: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public n'ort:.a, hire, Sanitary Server District, 3c000t D' TI bused on the reinari information available and are only art esdinale. Contact the Dept or aildn'l info. lAtrct. etc.). test. el4 are lim FEE ITEMS (Fee csolution 11-053 Elf 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Sttppl. PC Fee PME Plan Check: $0.00 Permit Fee: .4uppl. Insp I'ee PME Unit Fee: $10.00 PME Permit Fee: $45.00 Consimcdon Tax: Administrative Fee: IADAIhv $42:00 Work Without Permit? O Yes Q No $0.00 Advanced Planning Fees: i Travel Documentation Fee: ITRAI DOC $45.00 Strong Motion Fee IRSEISAIICO $0.50 Select an Administrative Item Bldg Stds Commission 17ce: IBCSSC $1.00 SUBTOTALS: $143.50 $0.00 TOTAL FEE: $143.50 Revised: 07/01/2012 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT ,DEPARTMENT • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTiNO, CA 950143255 (408) 77777-3228 • FAX (408) 7777-3333 • building r(- CUOerInO.Dr7 I�f?LL-M3 LNG I1 Arc-ANCAr. Int( ,ral nA.rtcmre,.rn„c 1 2cD R 0 Z3` PR03ECT.A.DDRESS APN"_- / •,•• 1 OWNER NAME u 1 HONE SMAE- STRFT ADDRESS �� AAWrO I C -y, Sfi Y� 'D O FAX CONTACT NAME I PHONE I E.MAZ S -L=: ADDRESS Cry, SAT FAX OWNER ❑ OWNER -BUILDER G OWNE2i AGN, CONTRA[; OR❑CONTRACTOR A0- C'I ARC= -Cr ❑ E•'GYE,�. ❑ D-Y*OjM ❑ CON TRACTOR NAM'c E Y4.flER .lf�_ aus. LICq CONSPANY NAME. -_MAZ I .AX 717 8-7 SST ADDRESS C'TY, STAT; I PHONE NA'.0 I UC=JSc Mul'sER I BUS. LIC i CON ANY NAME' I E -MAR- I FAX ST , ADDRESS I CIT`.', STA: Y 13 PHONE USE OF ❑SIM MTP_9C ❑ WIJ ,-,FAMILY BUU-ONG: OMNff.'+CIAL PROt IN Wy' L ❑ lYES7R0IECr UA INTcRFACEAREA NO ?1 ❑YES FLOOD LANE 0 I LS THEBLDG.W ❑ YES ECfLR Y-OMc. NO DESCRIPTION dF WORK Re 0 P,TwAjQ 6AJ JaQQX 6,e4(j() IA.) P 4Q Ak IOTAL VALUATION: Q I RECEIVED BY: 3y my sign=c below, I c^y to eacho`:he application and the in"or,-,ation I have p ordinaic3 and stere laws r-_latirg :o bui Signa t ofApplcant/Agene .allowing: I z✓ the umocl o mcr or zuthcrized agent to act on the ampe:y owner's behalf. I have road this 'ded s cor-cL I Save mad Cie Description o: Work and veiny it is acre a -. I agree to comply adth all applicable local .ng ns err I� ;h rze :epmscta4ves of Cutoe c :o cne: ;he M, ideodae3pr c-.� r inspection ou:pescs. pu: /�•. 2ponC S _ C-N-TAL R'QLjaED OFFICE USE ONLY t, ? V tc U OVER-THE-COUVTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ NwoR AsEPMualAp_2011.doc revised 0601/11 v7