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12080234CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR OWNER'S NAME: THE I:ORUM RANCHO SAN ANTONIO OWNER'S PRONE: 6509440100 ❑ LICENSER) CON"I'RACI'OR'SDI?CI \R,\'['ION License Class l I D Lic. #_t/ -717 / S Z Contractor h ISS/o ri ElAt L Qo (�wate —2 2 —( L 7 hereby affirm Ilial I am licensed trader the prrovisions of Chapter 9 (commencing with Section 70(10) of Division 3 of the Ilusincss S I'ridessions Code and Ilun nblicense is in full force and effect. 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, lot the pertormance 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 perfomumce of die work for which this penilit Is issued. APPLICANT CERTI FICAT'ION I certify that 1 have mad 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 ofthis city 10 enter upon the above mentioned property for inspection purposes. (We) agree to stat indemnilj• 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 :aid will comply with all non -paint s am regulati is per the Cupertino Municipal Code, Section 9.18. 1 Signature - Date__/ Z ❑ OWNER -BI If LI).ER DECLARATION I hereby affirm that I am exempt from the Contractor's Licensr Lan' for one of the follon'ing two reasons:. I, tis 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 R Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business B Professions Code). 1 hereby affirm under penally of perjury one of the following 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 employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, afier making this certilicateof exemption, 1 become subject to the Worker's Compensiaion provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be decried revoked. ,U'1'LIC.\N'1' CG12'I'I PIC.VI'ION I certify that I have read this application mid state that the above infomtation is correct. I agree to comply with all city acid county ordinances and state Imes relating to building construction, lard hereby authorize representatives oflhis city to enter upon die 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 CONTRACTOR: MISSION VALLEY PERMIT N0: 12080234 ELECTRIC INC 1'0 BOX 3332 DATE ISSUED: 08222012 FREM0\ f, CA 94539 1'II01NE NO: (510) 7458847 BUILDING PERNIIT INFO: BLDG r ELECT r PLUMB r NIECII r RESIDENTIAL r COMMERCIAL r JOB D ESCR I PTION: INSTALLATION OF ONE(I) 30 AMP CIRCUIT FOR IYftR. -Dleleg Sq. FI Floor Area: I Valuation: $2000 .0 IN Number: 34254999.00 1 Occupancy,[,) PC: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR ISO DAYS FROM LAST CALLED INSPECTION. Issued by: rJ Al Dale: -*'&-FR Ig BEI -ROOFS: All roofs shall be inspected prior to any roofing material beiig installed. If a roof is it lalled without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOK COVERINGS T'O [IF CLASS "A" OR RE ITFR IIA%ARDOUS MATERIALS DISCLOSURE have read the hazardous materials requirements under Chapter 6.95 of the California Health S Safety Code. Sections 25505, 25533. and 25534. 1 will maintain compliance with the Cuperlino Municipal Code. Chapter 9.12 and the Health S Safety Code. Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipninn or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the faith S Sit cl '- ode, Sections 25505, 25533, and 25534. DWlle authorized ager/ _ZZ — I�A late: f CONST'RUCT'ION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this pemrit is issued (Sec. 3097, Civ C.) Lender's A R CH IT EM"S DECLARATION I understand my plans shall he used as public records. Licensed �� TY OF CUPERTINO F FEE ESTIMATOR -BUILDING DIVISION WFADDRFSS,-2�japlendor FEE ID DATE: 08/22/2012 REVIE\VED Bl': Sean UNITS APN: BI'#: 'VALUATION: $2,000 *PERMITTYPE: Electrical Permit PLAN CIIECK TYPE: Alteration / Addition / Repair PRIMARY USE: Multi -Family Dwelling Buildina is >3 Stories O Yes O No PENTAMATION PERMIT TYPE: 1REAP NVORK Installation of 1 30 amp circuit for dryer. SCOPE APPLIANCE / EQUIP TYPE. FEE ID Plumb. Plan Cheek Q'1'1' UNITS BP FEES Elec. Permit Fee: IEPERAHT Special Circuits 1BREMMISC Other Elec. Ins P. 0.0 hrs $45.00 1 # $133 Permit Fee: Supp/. /nsp Fee PML' Unit Fee: $133.00 PME Permit Fee: $45.00 Consmuction Tar: Administrative Fee: (ADMIN $42.00 Work Without Permit? O Yes Q No $0.00 TOTALS: i Travel Documentation Fee: ITRA VDOC $133.00 Strong Motion Fee: IBSEISMICR NOTE: This ectioaue does not include fees doe to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). There feev are based on the preliminarl information available and are only an estimate. Contact the De t or adeln 7 info. FEE ITEMS (Fee Rewhaion II -053 Ell' 7/1/11) Atech. Plan Check Plumb. Plan Cheek Elec. Plan Check 1 0.0 1 hrs $0.00 Much. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERAHT Other• Afech. Insp, Other Plumb Insp,Ll I Other Elec. Ins P. 0.0 hrs $45.00 ,%*.ch. hap. Feer Plumb. hrap. Fee: Eler. Imp. Fee: NOTE: This ectioaue does not include fees doe to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). There feev are based on the preliminarl information available and are only an estimate. Contact the De t or adeln 7 info. FEE ITEMS (Fee Rewhaion II -053 Ell' 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Supp/. PC Fee PME Plan Check: $0.00 Permit Fee: Supp/. /nsp Fee PML' Unit Fee: $133.00 PME Permit Fee: $45.00 Consmuction Tar: Administrative Fee: (ADMIN $42.00 Work Without Permit? O Yes Q No $0.00 Advaneccl Planning Fees: i Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item 13ldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $266.50 $0.00 TOTAL FEE: $266.50 Revised: 07/01/2012 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (A08) iii -3333 • buildinclDr cuoerdno.orc ?LL?.IILNG . FlM7cCA'nr-47 xkeT cruraI I—ll..rr:cm I Z,:�) ? Jz3y MEP 1 PROTSADDRESS �' 3 Soa C ✓Z/ S zi IZGti `�.'J .kFN /Z / I ^ •.•• ___ _ ..,, OWNER NAME FOS IZu Iti PHONE y-DIoQ �MAE. STIL= ADDRESS I CIiY. iiAi=, Zi I✓I �FAx COKACi NAME PHONE -5- /0 5 ZZ _ MAz SFR=ADDRESS I CiiY, rATZ v FAX ❑ OWNER ❑ OwNER-BuIDEt ❑ OWN.'R AGEN7 JZ CONPAACTOR ❑mD, CTOR AGE+r ❑ ARCivT=Ci ❑ E�'CBJEr.Z ❑ D_N10PER ❑ T=NAN; coxT-RAcroaN c RNAN �I/ C .S ,o '��- ,�70 3 I u G-�1 O Bvs.L:co COMPANY NAME ✓ f� I SSI o. - N� _ Ax F S/o-7Ys-o ati� SiF ADDRESS 3'22— �✓c>z� �� , I TA iT. ZIP = ,-e),jT- c 9ys3� P90NE s,o s -may ARC��II]NGIN—R-.� 'AME LIC -NSE NUMBER . BLS. IJC p COMPANY NAME ' E.MA' I FAX STi.L--Er ADDRESS I C>~, STAT--Z� I PHONE USE OF ❑ SPO er DUPr =v MULi 1 -FAMILY I BLRLDRtG. ❑ cowj MRC: ?RDIECr N wIlDL ANo ❑ YPS Up9AN INTERFACE. AREA NO I PRDr-z, RI ❑YDS FLOOD ZONE 0 I IS THE BLDG AN YEs EC LER HOME. O DESCRIP"iIONO-rwORR . INS7-? L ,` aze V64-C-"p-rL'p G,u1 TOTALVALUATION: 5:V0 e1 I RECEL cJBY: �L/1 3y my sip==.- below, I cry to each of :he rollowcg: I, the ornoc.;/ own, cr authorized zgeat to act= the properly cw ee,'s behalf. I have read d s application and the' I have vided is co .rete I have rad eSe Descrpdoa or Work and ve:iy it is ace;--zte. I agree to comply with all applicable local ordinances and sate laws relad ding ccns—'xtiI znborze rn:e5ezaves cf Cuperd--c _ ^m::hc above-id=d5ex ,or inspection pu:peses. SigDan:_ of Applicant/Agent Date: SUPPLE1vCNTAL INFOR.VLATi ON kEQUIaZ-ED OFFICE USE ONLY i u _ L L OVER-THE-COUh TER EXPRESS ❑ STANDARD ❑ LAROe Cl AWOR !fE'P1 &c!pp_2011.doc revised 06/21/11