12080296CITY OF CUPERTINO BUILDING PERMIT
DO LII LNG ADDRESS: 23500 CRISTO REY OR UNIT 109CI eOeC"I,fR C 'OR: MISSION VALLEY I PERMITNO: 12080296
OWNER'S NAME: MCGOVERN DAGNA A TRUSTEE
PO BOX 3332 1 DATE ISSUED: 08282012
OWNER'S PlIONE: 6509440100 I FREMONT, CA 94539 I PHONE NO: (510) 7458847
LICENSED CONI'RAC-FOR'S DECLARATION
License Class- C — I0 Lie. 9 Y -7 0 / 3 2--
Contmctolb-551v r✓PcLtEX 9FZCW1ilifa1e g-IZ
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Sen ion 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 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, 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.
.U'1'LIC.yN'I' CFR'fIFICA'I'ION
I certify that I have read 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, mid 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 applicmm understmmds and will comply
with all non -point a ince regulations per the Cupertino Municipal Code, Section
9.18.
Signature c _ Date
❑ OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, as 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 & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the follmving 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 the 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, ager 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 this permit shall be deemed revoked.
APPI.ICAN7' CER't'IFICA'I'IO,N
I certify that I have read this application mid state that the above information is
correct. 1 agree to comply with all city and county ordinances and 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 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.
Signature Date
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB rl
MECH _ RESIDENTIAL — COMMERCIAL 7
JOB DESCRIPTION: UNIT 109C- INSTALL: RECESSED LIGHTS AT BEDROOM
LOCATION
Sq. FI Fluor Area: I Valuation: $1000
APN Number: 34253018.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b):; L_
RE -ROOFS:
All roofs shall be inspected prior to any 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
ALL ROOF CONTRINGS TO BE CLASS "A" OR BETTER
]HAZARDOUS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California llealth & Safely Code. Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the llealth &
Safety Code. Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined b)the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
llealth &Safety Code, Sections 25505, 25533, and 25534.
Date: r Z?�_ /-;_;, __
CONSTRUC`fION LENDING AGENCY
I hereby affirm thin there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCIIITFCI"S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Building Department
City Of Cupertino
10300 Torre Avenue
CUPERTINO
Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS:Z35oo G2,s 2.d}
PERMIT# Gl%Z
OWNER'S NAME: 25 _ Go✓E2 J
PHONE # 5'1O -7 5-88
GENERAL CONTRACTOR: h11-55710'.) lAmi L LLQ
BUSINESS LICENSE #
ADDRESS: -37? „/E�ra�E�
CITY/ZIPCODE: F vo +r 9y 5-36
Our mumcipal cone requires all businesses working in the city to have a.City of Cupertino business license.
NO BUILDING. FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL S CONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
am' not using any subcontractors:
ature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date
CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
APPLIANCE / EQUIP TYPE
FpDDRESS: 23500 cristo rey dr.
DATE: 08/28/2012
REVIEWED BY: bobs.
UNITS
N:
BP#:
'VALUATION:
$1,000
*PERMIT TYPE: Electrical Permit
PLAN CIIECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE: p
$67
PENTAMATION
1REAP1
PERMITTYPE: dl
WORK
install recessed lights at bedroom location.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Phunb. Plan Check
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERAHT
Fixtures, Lighting
iBREMFIXT
Other Elec. Insp. 0.0 hrs $45.00
4
#
$67
Permit Fee:
Suppl. hhsp Fee
PME Unit Fee:
$67.00
PME Permit Fee:
$45.00
Consnvction Tat':
Administrative Fee: (ADMIN
$42.00
Work Without Permit? O Yes (j) No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRAVDOC
$67.00
Strong Motion Fee: IRSEIS,MICR
NOTE: This estimate does not include fees tlue to other Departments (i.e. Planting, Public Works, Fire, Sanitary Selmer District, School
District, etc). These fees are baser/ on the preliminary information available and are only nn estimate. Contact the Deptjor addn'I info.
FEE ITEMS (Fee Resohninn 11-053 EB' 7/1/11)
,tlech. Plan Check
Phunb. Plan Check
Elec. Plan Check 0.0 1 hrs $0.00
Mech. Permit Fee:
Plumb. Permit Fac:
Elec. Permit Fee: IEPERAHT
Other ,tle,A Insp.
Oiher Plumb Insp.
Other Elec. Insp. 0.0 hrs $45.00
klech. hhhp. Fec:
Plumb. btap. Fee:
Elec. Insp. Fee:
NOTE: This estimate does not include fees tlue to other Departments (i.e. Planting, Public Works, Fire, Sanitary Selmer District, School
District, etc). These fees are baser/ on the preliminary information available and are only nn estimate. Contact the Deptjor addn'I info.
FEE ITEMS (Fee Resohninn 11-053 EB' 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
suppl. PC Fec
PME Plan Check:
$0.00
Permit Fee:
Suppl. hhsp Fee
PME Unit Fee:
$67.00
PME Permit Fee:
$45.00
Consnvction Tat':
Administrative Fee: (ADMIN
$42.00
Work Without Permit? O Yes (j) No
$0.00
Advanced Planning Fees:
A
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: IRSEIS,MICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee. IBCBSC
$1.00
SUBTOTALS:
$200.50
$0.001
TOTAL FEE:
$200.50
Revised: 07/01/2012
fC—�UPERTINO I
I I �iFW !-flNC�tfI�T/1N
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildino(Qcuoer5no.oro
FI A nnITI iON 1 ALITRATION / TI 1 REVISION / DEFERRED ORIOMAL PF.WTT Y L / a
PROTECT ADDRESSAPN I
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CONTACT NAME I PHONE E-MAIL
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CITY, STATE ZIP
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❑ OWNER OWNER-BIMLDER ❑ OWNEKAGENT CONTRACTOR ❑ CONTRACTORAGENT Cl AaCHrrECT ❑ ENaNszR-+ ❑ DEVELOPER ❑ TENANT
CONTRACTOR
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STREET ADDRESS
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ARCHTTEC IENGiNEER NAME
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COMPANY NAME
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STREET ADDRESS
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PHONE
DESCRIPTION OF WORK
6 E$GE C L, Gc,�T,zdc�
NGPnS, ,�i�s5 r+—r
EXISTING USE PROPOSED USE
CONSUL TYPE
4STORIFS
USE
TYPE
OCC
SQFT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET.iRF\
I DO
BATHROOM KITCHEN OTF{ER
REMODELAREA RENODELAREA REMODELARE-
P00.CH AREA DECK AREA 70TAL DEC.C?ORCH AREA WLIGE AREA: DETACH
ATTACH
0DWELL24G UNITS:
IS A SECOND U�TT CITES
BECONDSTORY ❑YES
BEING ADDED" NO
CI
ADDITIOr. CINO
PRE -APPLICATION CITES 7 YES. PROVIDE COPY OF
IS THE BLDG AN ❑YES
RECEIVED BY:
TOTAL VALUATION:
PLANNDIGAPPL! []NO PLANNING APPROVAL L-rE3
EICELER HOME' CINO
By my signature below, I army to each of the following: 1 am the property owner or authorized agent to act on the prppJerry owner's behalf. I/have read this .
application and the information I have pm .4Fd is correct {.have read the Description of Work and verity it is accurate. I agree m comply with all applicable local
ordinances and sae laws tpla:sg b�iyrt'' g corrsracDon I authoriz- representatives of Cnper.:no m inter the abov/e�idrntiaed pmpery for inspection purposes.
Signature, of Applicant/Agem: Date:
SU-PPLEjv, ALINFOR:,fATIONREQUUtED
PuvcP�mcTYiE
ROUTINGSI-M
B
IS
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
0 THE -COUNTER
BttnDmc PLA,v REVIEW
permit for new building.
❑ EXPRESS
❑ PLANNLNGPLA.NREVIEW
Commercial Bldgs: Provide a completed Hazardous hfarerials Disclosure
❑ STAxDARD
❑ PUBLICwORHS
To—= if any Hazardous Materials are being used a5 part of this project.
❑
,
❑
LARGE
Fm DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ xA.Tox
❑
submittal of Building Permit application.
SANITARY SEWER DISTRICT
❑' E:vvmON:.NT.AL BEALTH
BldgApp_2011.doc revised 06/21/11