12100062CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 421F
CO\ FRACFOR: MISSION VALLEY
PERMIT NO: 12100062
ELL•CTRIC INC
OWNER'SNAME: LILLIAN SLAVIN
PO BOX 3332
DATE ISSUED: 10/092012
OWNER'S PHONE; 6509440100
FREMONT, CA 94539
PHONE NO: (510) 745-8847
❑ LICENSED CO\FRAC`fOR'S DECLARATION
.JOB DESCRIPTION: RESIDFN fIAL U COMMERCIAL,
License Class C —t 6 Lie. k Y-ZU 13 �
REPLACE 30 RECEP, 12 SWITCHES,.2 OUTDOOR LIGHTS,
I' cc
Jj4LLdYGlO�
INSTALL 2 HEAT LIGHTS, REPLACE 2 EXHASUT FANS,
rl
Contractor 1551oz1
REPLACE KITCHEN LIGHTS WITH 4 RECESSED LIGHTS,
1 hereby affirm thou I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that m)license is in full force and effect.
hereby affirm under penalty of perjury one of the following boo 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
Sq. Ft Floor Area:
Valuation: 54000
performance of the work for which this permit is issued.
1 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
\PN Number: 34253185.00
oecnpaney'fype:
permit is issued.
APPI,ICAN7' CER'1'IFIC,\']'ION
1 certify that I have read this application and state that the above information i5
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state Imus relating
NVITHFN IAO DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
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upon the above mentioned property for inspection purposes. (We) agree to save
5'
180 DAY ROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
,
costs, and expenses which may accrue against said City in consequence of the
' /O
Issued by; Date: L
granting of this permit. Additionally, the applicant understands and will comply
with all non -points u e egulana s per the Cupertino Municipal Code, Section
9.18.
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Rr: Roars:
Signature Datc
All rools shall be inspected prior to any roofing material being installed If a roof is
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installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that 1 oat exempt from the Conlrador's License Law for one of
the following two reasons:
ALL ROOF COVE121NGS TO BE CLASS "A" OR BETTER
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)
I, as owner of the property, am exclusively contracting with licensed contractors to
IIA%ARDOUS MATF,RIALS DISCLOSURE
construct die project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ileallh & Safely Cotte, Sections 25505, 25533, and 25534. 1 will
hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safely Code, Section 25532(x) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or deices which emit hazardous
Compensation, as provided for by Section 3700 of One Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this pemnil is issued.
will maintain compliance with the CuPgrlino Municipal Code. Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Ilcalth & Safety Code. Seclinns2 505. 2553 �anJ 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Date: to
Owner or authorized agent: •
permit is issued.
/
I certify that in the performance of the work for which this pemrit 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, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLIC,\N'I'CFR'I'IFICAq'ION
Lender's Address
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
ARCI11TECI"S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
igADDRESS:
23500 cristo rey
[AP
DATE: 10/09/2012
REVIEWED BY: mendez
Mech. Permit Fee.:
N:
BP#:
'VALUATION:
$4,000
*PERMITTYPE: Building Permit
PLAN CIIECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
Elce. Insp. Fee:
PENTAMATION 1 REAP10
PERMIT TYPE: dl
WORK
unit 421 F- replace 30 rece . 12 switches 2 outdoor lights, install 2 heat lights, replace 2 exhaust fans
SCOPE
replace kitchen light with 4 recessed lights replace 2 vanity lights
NOTE: This estintate does not include fees due to other Departments (i.e. Planting, Public Workts, Fire, Sanitary Server District, School
District, etc). These fees are bared on the prelitninan, information available and are onlP on a butane. Contact the Dept for addn'I info.
FEE ITEMS rl'ee Resolution 11-053 EO' LL I)
,blech. Plan Check
Plumb. Plan Cheek
Elec. Plan Check 1 0.0 1 hrs $0.00
Mech. Permit Fee.:
Plumb. Permit Fee.
Elec. Permit Fee: IEPERAfIT
Other Afech. Insp.
Other Plumb lnsp,
Other Elec. Insp. 0.0 hrs $45.00
11e.ch. Insp. Fec:
Phoub. Insp. Fee:
Elce. Insp. Fee:
NOTE: This estintate does not include fees due to other Departments (i.e. Planting, Public Workts, Fire, Sanitary Server District, School
District, etc). These fees are bared on the prelitninan, information available and are onlP on a butane. Contact the Dept for addn'I info.
FEE ITEMS rl'ee Resolution 11-053 EO' LL I)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$133.00
Electrical
IBREMRECEP I Recep/Switch/Outlets
Suppl. PC Fee: Q Reg. Q 01
0.0
hrs
$0.00
PME Plan Check:
$0.00
12
$67.00
Electrical
IBREwFUT Fixtures, Lighting
Permit Fee:
$0.00
Suppl. Insp. Fee.S Reg. Cl OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
Conct•ttction Tar:
Administrative Fee: IADHIN
$42.00
O
E)
Work Without Permit? Cl Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
G
i
Travel Documentation Fee: ITRAI'DOC
$45.00
Strong Motion Fee: IBSEISAIICR
$0.50
Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $133.50
$200.001
TOTAL FEE:
$333.50
Revised: 10/01/2012
CUPERTINO
GENERAL PERMIT APPLICATION E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 �� jJ p p I S C
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(408) 777-3228 • FAX (408) 777-3333 • buildinc c cucertlno:ora 1 \
I IPLU-,IMNG n'MRCF4--k'MCAL NELECC3ICAL nMi t a�nitc
PRor ADD? ESS soo i�j -D L2, �.wa 2- 1 F .�1A
OWNER NAME
F-DIZU&,ULLI(:n SIAVIr)
PHONE
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ST.=. ADDRFSS
I CITY. STATE M?
I FAX
CONTACT NAME
PHONE
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ST?=ADDRESS
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FAX
❑ OWI ❑ OWNER -BUILDER ❑ OWNER ACm. PJ CONTRACTOR ❑CO.'. CTOR AGENT ❑ ARCETECf ❑''.GNEEX ❑ DEVELOPER ❑ TE
CO- AOR NMME
-
L'CIIISE NUMBER LICEYSE TYPE
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BUS. LIC i
CO MPA.W NAME 11 E-MAIL
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FA.Y ry
S[O-7sfS -BZYp
STRER ADDRESS Cf1Y TATE IIP
0 3332 2cA-co,-+T - CSP- 9YS3q
PHONE
Sto•7 S-?YV
ARCHTIECTIENGLNEER NAME
LICENSE NUMBER
I BUS. LIC a
CO,NPANY NAME
E-MAIL
FAX
SIR— ADDRESS
CI".STATE ZIP
PHONE
USE OF ❑SFO-DUPLFX ❑ MULTI-FA.YIE.Y
BUIIDNG: ❑CO.. . I:UI.
PROTECT IN WIDL ND ❑ YES
URBAN[NTZIFACEAREA ❑ NO
PROTECT) ❑TES
FLOOD ZONE ❑ NO
IBTHEBLDGA.N ❑ TES
EICHI.DI HOME± ❑ NO
OESCRIP^ON OF WORX
F �-� 30 —P /z ,r -cc, -t a oo I oofL LE ti-iS'
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4 P�c�ss LEI Lc �+ S
lL Lt�Gcr z ✓la IJ T 1 tt s
TOTAL vALUATIONiw�- a0D % - I RECEIVED BY:
By my signature below, I certify to each o; the ;ollowing: I am the property owner or authorized agent :o act on die property owner's InchaF I have t --ad this
application and the iniomuduc I have provided is correct. l Tuve read the Description ofWork and verity is is accurate [ agree to comply wiz all aaplicable local
ordinances and state laws relating m building cons action. I anrborim represent mrivcs of Cunerinc :o ;na::.be above-identi5cd prove. -y :or inspection uu -poscs.
SigLan:r-_ of Au Date:
SUPPLENM1,7AL INFOR.NLATION REQUPRED
OFFICE USE ONLY
v
❑ OVER-THE-COUNTER
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-
Cl EMPRESS
U
u
U
❑ STANDARD
L
❑ LARGE
❑ MAJOR
Aff`uclpp_201 Ldac revised 06121111