12080219CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 519G
CON1'RACI'OR: BAY AREA ENTERPRISE
PF,RMI TNO: 12080219
O\\'NIiK'S N,WIIC: RUSSELL GRANT E
2110 NL\NGIN WAY
DA'Z'E ISSUED: 0821/2012
OWNER'S PHONE: 6509440118
SAN' JOSE. CA 95148
PHONE NO: (408)238-5043
❑� LICENSED CO\ I'RACIOR'S DECLARATION
r r r
BUILDING PER;\IIT INFO: BLDG ELECT PLUDIB
License Class l7 Lic. d 81 1
r_ rr�
I-
r/
/;J(� a �r ��- C Date
RIECII RESIDENTIAL
JOB DESCRIPTION: REPLACE SROER PAN AND WALLS — x4 nl�- 51 q
1 hereby affirm that Ian licensed under the provisions of Chapter 9
(commencing with Section 7000) (if Division 3 of the Business S Professions
Code and That nn' license is in full force and effect.
1 hereby affirm under penalty of perjury one of the fullowing nvo 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.
Sq. Ft Floor Aren:
Valmnion: $4500
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this
APN Number: 34253235.00
Oecupaney T3 PC:
permit is issued.
APPLICANT CERTIFICATION
I certily that I have read this application mid state that the above information is
correct. l agree to comply with all cityand county ordinacesand state Imes relmine
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgnnenis,
costs, and expenses which may accrue ag' st said City in consequence of the
180 DYS FROA1 T CALLED INSPECTION.
granting of this permit. Additionally, th pplicam understands and will comply
D
with all non -point source regal ti s p the Cupertino Municipal Code, Section
Issued by: !�� / Date:
9.18.
Signature Date
RE -ROOFS:
❑ OWNER -BUILDER DECLARATION
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
hereby affirm That I am exempt from the Contractor's License L my for one of
inspection.
the follmving two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
will do the work, mid the structure is not intended or offered for sale (Sec.7044,
Business S Professions Code)
'
I, as owner of the property, am exclusively contracting with licensed contractors to
ALI, ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business S Professions Code).
1 hereby affirm under penalty of perjury one of the following Three
IIA--/.ARDOUS MATERIA\ S DISCLOSURE
declarations:
T have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to sclf-insurc for Worker's
California llcalth S Safciv Code. Scelions 25505. 25533, and 25534. I will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance w'itb [lie Cuperlino Dlunicipal Code, Chapter 9.12 and the Ilealth S
performance of the work. for which this pemmit is issued
Safety Code. Section 25532(x) should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided tort by
Additionally, should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
cnntnminams ns fined by the Bay Area Air Quality Management District I will
'n
permit is issued
moim comp ice with the Cupertino Municipal Code, Chapter 9.12 and the
n Z;'d
S Safe. 'Code Sections 25505. 25533, and 25534.
1 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 law, of Calil-omia. If, after making this certificate ofesemption, I
O r u norizrd agent:
Date:
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
CONSTRUCTION LENDING AGENCY
I hereby alfnn thin there is a construction lending agency for the performance of xwrk's
APPLICANT CERT1 FICATI ON
for which this permit is issued (Sec. 3097, Civ C.)
I.certiN than I have read this application and state thin the above information is
Lender's None
correct. I agree to comply with all city and county ordinances aid slate laws relating
to building construction, and hereby authorize representatives of city to enter
Lender's Address
upon the above mentioned property for Inspection purposes. (We) agree to save
indemnify and keep harmless the City ofCupenino against liabilities -judgments,
costs, and expenses which may accrue against said City in consequence of the
ARCI I ITECI"S DECLARA'T'ION
granting of this pemmit. Additionally, the applicant understands and will comply
I understand my plans shas all be used public records.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Licensed Professional
Signature Date
r CITY OF CUPERTINO
I_�N FEE ESTIMATOR -BUILDING DIVISION
NOT/;: This winmte does not includejees dire to other Departntents (i.e. Planning. Public /forks, Fire. Sanitary Server District, School
District,ere.). These fees are based on the nrelitninan' information available and are onh, an estinuue. Contact the Dent for aildn 7 info.
FEE ITEMS (Fee Re.sohnion 11-053 El 7111//)
ADDRESS: 23500 cristo reV dr #519G
DA'Z'E: 08/21/2012
REVIE\VED Bl': larrys
bfeclr. Pernt/t Fee:
.\I'N:
BP#:
'VALUATION:
$4,500
*PE1011,1, 1'VPE: Building Permit
PLAN CIIECK'1'1'PE: Alteration / Repai
PRIMARY'
USE: SFD Or Duplex
Elco. hrsp. Fee:
P ENTANIATION
PERMIT,rYPE: 1R SF E
(YORK
bathroom remodel
SCOPE
$0.00
NOT/;: This winmte does not includejees dire to other Departntents (i.e. Planning. Public /forks, Fire. Sanitary Server District, School
District,ere.). These fees are based on the nrelitninan' information available and are onh, an estinuue. Contact the Dent for aildn 7 info.
FEE ITEMS (Fee Re.sohnion 11-053 El 7111//)
bfech. Ilan Check
Plumb. Plan Check
Elec. Plan Check
bfeclr. Pernt/t Fee:
Plumh. Permit Fec:
fact•. Permit Fee:
Other Sfech. Insp.
Other P lumh Imp.Ll
Other Elce. /asp.
Hoch. lmy. Fac:
Plumb. hrsp. Fee:
Elco. hrsp. Fee:
NOT/;: This winmte does not includejees dire to other Departntents (i.e. Planning. Public /forks, Fire. Sanitary Server District, School
District,ere.). These fees are based on the nrelitninan' information available and are onh, an estinuue. Contact the Dent for aildn 7 info.
FEE ITEMS (Fee Re.sohnion 11-053 El 7111//)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F120 s.f.
$600.00
Remodel, Bath (<=300 sl)
IREhfRESBAT
Suppl. PC Fee: Q Reg. Q OT
0.0
its
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
SuppI. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PNIF Unit Fee:
$0.00
PMG Permit Fee:
$0.00
Construction Tar:
Administrative Fee::
Q
E)
Work Without Permit? O Yes 0 No
$0.00
Advanced Plannine Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
0
i
Travel Docranentanan Fees:
Suooa Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$600.00
TOTAL FEE:
1 $60/50
Revised: 07/01/2012
I
u
I 1
CUPERTINO
—
1 NPW rY)NSTrt1Ir
I20� 0-1-I9
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingecupertino.org/_
rTnN I I AI)T)1'1'1ON KI AITPNATI(W/'I'I M RFVISIr)Nmrri:n RHn (1RICHNALPERMITd
PROICLTAUDRiSSO(^n SOO `Y1S�
5
APNq
C�.l
R NAME
PHONE
E-MAIL•
Herriawdo J C-enru
STREET ADDRESSz 3So0 `Yr'S7Q A-.
/��
A fj
CIC, STATY�a
FAX `5 �_
O
f�
J
CONTACT NAME,
G� Fir,
PHONEO Z3�—�O�
E-MAIL Gr
,_oly
STREET ADDRESS
Mom ih L✓�a
CITY, S" l) ZN
ST
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT
IQ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEV-LOPER ❑ TENANT
CONTRACTOR NASME//�MGNr1
LICENS U R
L/IC�ENSE PE
BUS. LIC 9 Q7.3
/
,2
COMPANY NAME d
VQ
E-SIAIL
r
FAX
V09-613-159Q
STREETADDRES
C
CITY SA
TZf(
Y
PHu E
ARCIIIT17C"T/ENGINEER NAME
LICENSE NUNIBE
BUS. LICK
COMPANY NAME
&SIAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
�J
EXISTING USE
PROPOSED USE
CONSIR.TYPE
M STORKS
I
USE
TYPE
OCC.
SQ.FT.
VALUATIONS)
EXISTG
NEW FLUOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM KITCHEN
OTHER
REMODEL AREA REMODEL AREA
REUODELARG
PORCH AREA DECK AREA
TOTAL DECKIPORCII ARG GARAGEAREv DETACH
[J ATTACH
0 DWELLING UNITS:
IS A SECOND IINI'IEl YES
SF.CONDS'1'IIRY ❑YTS
BEING ADDED? ❑NO
ADDITION" ❑NO
PRL' -APPLICATION ❑YTS IF YES, PROVIDE COPYOF
IS TI I f: RLDG AN ❑1'Es
RECEIVED BY:
TOTAL VALUATION:
PLANNING APPL4 [J NO PLANNING APPROVAL LLTr[A
EICHLF.R HOME? E] NO
BY my signature below, I certify to each) the following:
I am th p ape y owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have 'ided is correct.
I have . d t �yescription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to it inlg�I�,oyst trio
. . • e resentatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicmldAgenC vV[�
Dale: L�— Z/
SUPPLENIEN 'AL INPORbL •I'ION REQUIRED
PLAN CHE:CK'I YPE
ROvrING s1.U'
❑
❑
New SPD Or Multifamih• dwelling ' pply for demolition permit for
_
existing building(s). Demolition permit is required
prior to issuance of building
OVEWI RE-CIIUN'I ER
BUILDING PLAN REVIEW
permit for new building.
❑ EXPRP.ss
❑
PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed I la'rardous
Materials Disclosure
El STANDARD
ElPuB1.lewoRKs
Tom if any Hazardous Materials are being used as pan
of this project.
❑
❑
LARGE
FIRE DERT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑
❑
submittal of Building Permit application.
MAJOR
S,\N'1'1'.\R\'SF.%1'F.R DISTRICT
❑
F:uvlRocaus'r,u. uF:AI.Tu
BldgApp_201 Ldoc revised 06121111
MRa
L
I