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12090150CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY OR UNIT 223D CON'T'RACTOR: MISSION VALLEY PFRDIIT NO: 12090150 ELECTRIC INC OWNER'S NAME: BROGLIATTI GEORGIA li TRUSTEE PO BOX 3332 DATE ISSUED: 09/182012 OWNER'SPIIONE: 6509440100 FRF-MONI'. CA 94539 PHONE NO: (510) 745.8847 ❑ LICENSED CONI'RACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT IJ PLUMB r License Ctass , — / O Lic.d Contractor Date 1 hereby affirm that I am licensed under the proN isions 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. MECIi C RESIDENTIAL I✓ COMMERCIAL C .1013 DESCRIPTION: UNIT 2231)- INSTALL 7 LED LIGHTS AND REPLACE 12 SWI TCI IES AND 27 RE•CEPUCLES.REPLACE 2 EXHAUST FANS AND INSTALL 2 HEAT LAMPS 1 hereby affirm under penalty of perjury one of the following mo 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 doe work for which this Sq. FI Floor Aren: permit is issued. APPLICANT CERTIFICATION 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, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep hamdess the City of Cupertino against liubil itics, judgments, costs, and expenses which may aceme against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply With all non -point so reg regulations per the Cupertino Municipal Code, Section 9.18. �j Signature Date ❑ OWNF,R-BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for one of the following twvo reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, mid the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). hereby affirm under penalty of perjury one of the following three declarations: 1 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 perlbmiance 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, Ibr 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 Cali forma. If, after making this certificate ofexemption, 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. APPLICANT CERTIFICATION 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, 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. APN Number: 34253069.00 Valuation: $5000 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 18 DAYS OF PERMIT ISSUANCE OR 180 DAYS -,l 0, LAST CALLED INSPECTION. Date: RF -ROOFS: All roofs shall be inspected prior to any roofing material beiig installed. Ira roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Date: ALL ROOF COVERINGS TO RE CLASS "A" OR BETTER I IAZARDOUS MAT'ERIAI S DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 critic California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance With the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the tial' Area Air QualityManagement District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safeely Code,/Sections 25505, 25533. and 25534. Ow r'ny (a ized8/nh •s / / Date: / U CONST'RI1CI1ON LENDING AGENCY 1 hereby affirm thm 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 Leader's Address ARCI ITEICT'S DECLARATION I understand my plans shall be used as public records. Date I Licensed CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 23500 CRISTO REY DR DATE: 09/18/2012 REVIEWED BY: Sylvia APN: BP#: 'VALUATION: J$5,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY PENTAMATION 1REAP10 USE: SFD or Duplex pERD11T TYPE: WORK unit 223 D- INSTALL 7 LED LIGHTS AND REPLACE 12 SWITCHES AND 27 SCOPE REPLACE 2 EXHAUST FAN AND 2 INSTALL HEAT LAMP Y ,Lk•ah. Plon Check P in& Plan Cheek Elea Plan Check 0.0 hrs $0.00 Aleclr. Par...I Fee• Pt,ndr. Pennir Fee: Elec. Permit Fee: IEPERUIT Odrer,ifech. Insp. Orher Plumb Insp. ED Other Elec. Insp. 0.0 hrs $45.00 :Neth. Imp. Fee: Plumb, Insp. Fee: Elec. Insp. Fre: NOTE: This estimate does not inewaejeer aue to otner ueparnne,w (i.e. r,a„n,r,g, , n.,, . •, ........-.1 -- -- _. _.._...._____,:.__:___.:_r___.,..:.._......u.,u.. ,...d n.,, n„noln,nro Cnnmrr rhe Dent for addn'(rn(o. vistrict. Em/nrve cc, ure auocu vn •..� .. ................. FEE ITEDIS (Fee Resolution 11-053 E8 7/11111 ......_...,.. ... _......._ FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 39 # Electrical $121.00 (BREAfRECEP Recep/Switch/Outlets Suppl. PC Fee: Q Reg. 0 OT0.0 hrs $0.00 PME Plan Check: $0.00 F 11 1 Electrical $67.00 1 /BREHFIXT Fixtures, Lighting Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. 0 OT rom I hrs $0.00 PME Unit Fee: $0;00 PME Permit Fee: $45.00 Conn uction To..: Administrative Fee: (ADMIN $42.00 0 E) Work Without Permit? 0 Yes (D No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential E) Building or Structure DA Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: IBSEISA4ICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 STOTALS: UB $133.50 $188.00 _ TOTAL' FEE: $321.50 Revised: afluilzulz CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 7777-3228 • FAX ('08) T-3333 • buildincnc. woertinc.orr 1 Z0R br MEP ❑PLUMBING ❑MEC==4NICAL RELECRICa.L Fl.eSCELL4NEOUS ' 11 A PROJECTADDRESS Z 3 SDCi G2/S a F�y / 2 .APN4 v N I T Z Z -J 2 - 'OWNERNAME OWNER NA.ME�E ZU ❑ �' Cl , PHONE E -MAR. STREET ADDRESS CTFY, STAT: ZIP FAX CONTACT NAME L2 AN�a �/a X� ONE I S/o-3oY-SZz MAz STREET ADDRESS I =1STATE ZI? FAX ❑ OWNER 0 OWNE-BUILDER ❑ OWNER AG'c0•ri ❑ CONTRACTOR ❑CON, CTOR AGE+T ❑ ARCS:cC: ❑ M40 -N mt ❑ DEV- PER ❑ T `lAtr; CONTRACT NAME CUTczN'S'c M3R NU M755/OrJ !/A(-L�" LLECi2/C ANG 70 3Z— L'C`''"SE TYP=_ �- 10 BLS. LC 7 3 ,� / Ons COMPANY NAME E -MAH, FAX F -T ADDRF_SS + v 3 3 3 2 STAT?; Z[P n PHONE s/,., - !iS - S'S'y •-7 A R 01= CTIE N G W—= NAME LiCc,SE NUMBER BUS. LIC4 COtiBANY NAME' I E-MAIL FAX SIR. -LT AD D RESS I CiSY, STAT -c, Z`3 PHONE USE. OF ❑SFJ. DUPLEX ❑ MUL-,FAMB.Y I BUILDING: cotamEACAL PRO.CTN WD— LAND YFS I U 3AN NF-cR: ACE AREA NO PRODtN ❑ Y s FLOOD ZONE El NO I S=BLDG AN ❑ Y�3 EICHLER HOME? ❑ NO DESCRDT,ON OF WOEC A+ 5 I Z 1 GH7S (VO, C ?-G� EXifP , S i FP N • 1�s��L NSA— L/ r� - ��c � /_ /� �� TOTAL VALUATION: +o!'%U I RECEIv BY: By my signan Sdow, I crj o tach o.`�e :o)Iowing: I as the epc:y owner or and:orized agent to ac: on the prdpp C-9G's behalf. t have :.ad dds application and die information. I have pav-ded is correct I have r_ad the Deseipdpn of Work and verify is is a=mzc.x comply Widt all applicable local ordinances and sax laws r<!aXir.g - bui)di co:tsrucri Int e.-:ze repracntad-+es of Cuperdu :o eo-: t: -.e ve-idcnutie3 pipe. ,• (;b�:or mspecnon pui# oscs. Signamm of Appiicant/Ageac Date: / - 16 - l z— SUPPLEMENTAL REQU-LRED FFICE USE ONLY ' U - L z < O VER-THE.COUNTER ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR 2d—,-7:4fse4pp_2011.doc revised 06/21/11 _C�C �s