12110042 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23800 AMAPOLO CT UNIT V2 CONTRACTOR:MISSION VALLEY PERMITNO: 12110042
ELECTRIC INC
OWNER'S NAME: PHYLLIS SIMPKINS PO BOX 3332 DA'Z'E ISSUED: 11/072012
OWNER'S PHONE: 6509440100 FREMON-l',CA 94539 P]IONF.NO:(510)745-8847
1Zf_ LICENSED CON-FRAC`fOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB ❑
License Class G- ID Lie.a Y 7d 3 z r r r
/'' MECH RESIDENTIAL COMMERCIAL
Contractor r / [/a� Z'Datc ��- 7 — / Z
hereby affirm that I am licensed under the prnrisions of Chapter 9 JOB DESCRIPTION: INSTALL(12)LED LIGHTS,(4)UNDERCABINEf LIGHTS,
(con]locating with Section 7000)of Division 3 of the Business S Professions (2)EXHAUST FANS,(2)I IEA'f 1.AMPS,REI'LACIi(16)SWITCIIES
Code and that my license is in full force and effect. AND(28)RECEP'fICLES.
hereby affirm under penalty of perjury one of the following hro declarations:
I have and will maintain a certificate of consent m 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(he work for which this Sq,FI Floor Area: Valuation:54500
permit is issued.
APPIJCVN'I'CER'1'I1.'IC,\TION APN Number:34254002.00 OccupancyTpc
I cenify 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 law's 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN IgO DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
graving of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulatia s per the Cupertino Municipal Code,Section
9.18. �h/
/ /-742— Issued by: `�— Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that 1 am exempt from the Contractor's License Lawfor one of All roofs shall be inspected prior to any roofing material being installed If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages is their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sea7044,
Business& Professions Code) Signature of AppliamC Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO RE CLASS"A"OR BE ITER
I 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 IIA'LARDOUS\LVTERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the labor Code,for the I have read the hazardous materials requirements tinder Chapter 6.95 of the
performance of the work for which this permit is issued. California Ilealth S Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth S
Safety Code.Section 25532(x)should 1 store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the[lay Area Air
Qunlil)'\lanagem gni District I will
I cenify that in the performance of due work forxvhich this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's I Ieallh S Sa y Cody.Sections 25505,25533,and 25534.
Compensation Imus of California. If,idler making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must 01 11 1horiz/ !gent:
forthwith comply with such provisions or this permit shall be deemed revoked. (late: !i-7 -17
AI'PLIC ,N f CERTIFICATION CO,NSTRUCIlON LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state lases relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned propeny for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgmems, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
gracing of this permit.Additionally,the applicant understands and will comply ARCI I ITEC`"S DECLARA'T'ION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
GENERAL PERMIT APPLICATION P
COMMUNI iY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 9501-1-3255 ImamI S C
CUPERTINO (4 08)T77-3228 • FAX(-108)7T/-3333•buildinc0cuoerana.om
❑?LUMBPIG ❑"MCF_A_xlC.AL A711LECTRLICALD.�t'iSCr L YEOUS
PROFS ADDRES��L�O 1} M !AC
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/l✓I / /V� PHONE - 9vy-D Io6 E,1
57REEr ADDRESS I Ci N. STAT',ZIP FAX
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CONTACT NAME I PHONE E-MAR.
STPEET ADDRESS CI .,STATE, IIP FAX
❑OWNLR ❑ 0Wt-BUR !Ut ❑ OWNERAGENT T CONTRACTOR ❑CONK COR AGENT ❑ ARCHITECT ❑E+GDMZ]t ❑ DEVELOPER ❑ VAN
CO?fiAACrOft NAME LICENSE NUMBER LICENSE TYPE I ELS.LIC i
I t '7d I L C_ t0 O
CON4ANY NAME E-MAIL FAX
SIO -7 s -O?-,/e
ADDRESS CIN,STAT$ZR' PHONE
- c�o>< 333 — a ; - - �'r }��5g /� - )YS- BTfk•
ARCRTECT,/ENGLNEEER NAME LICENSENUMBER I BUS.LICY
COMPANY NAME' E-MAIL FAX
STREET ADDRESS =.STATE ZIP I PHONE
USE OF ❑SED mDUPLEX TFFAARLY PROIF NwRDLWD ❑ YES I PRO ,W Yrs I IS THE BLD:AN ❑ M
RIRLOWG: C]co RCIAL URBAN P+TERFACZA NO FLOOD ZONE .O EICHL�R HOM NO
OESCRUMON OF WORK 1
Z — LE LI li-T 4- V l7cR-GA I =� t.7 Fri
Z E res _Z L P
TOTAL VALUATION: /_fSoo I RECEIVED BY:
By my signature below,I certify w each of the fallowing: I am the property owner or authorized agent to act on the property owner's behalf. 1 have rad this
appLcation and the inlarmatior.I have ptnvided is correct. 1 have rad the Description of Work and verify it is accurate. I agree m comply with all applicable local
ordinances and sate.laws reladr hl t g com. truc' I authorize rep adves of Cuperti_c_ L-
:^ :t.Se:.hove-id=E5cd pmpe.-;:or inspecrion puvposes.
Signare of ApRplicant7Ageae Das: - -
tuSUPPL NIENTAL.INFORIVLAIi0N REQUIRED OFFICE USE ONLY
a OVER-THE-COUNTER
Y
❑ EXPRESS
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❑ STANDARD
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a ❑ LARGE
❑ MAJ00.
MEP.Vuc.Ipp_2011.docrevised06/2iyll '
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
:M
ADDRESS: 23800 Amapolo Ct (Villa#2) DATE: 11/07/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: 1$4,500
*PERMIT TYPE: Electrical Permit =PLAN CII ECK TYPE: Alteration /Addition / Repair
PRIDL>,Rl' ,Multi-FamilyDwellingBuildino is PENTAMATION 1REAP10
USE: >3 Stories O Yes 1 No PF.RMITTVPE: Al
WORK Install 12 led lights, 4 undercabinet lights, 2 exhaust fans 2 heat lams replace 16 switches
SCOPE and (28) recepticles.
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Recep/Switch/Outlets 1BREMRECEP 44 # $141
Fixtures, Lighting 1BREMFIXT 16 # $67
Fixtures, Lighting 1BREMFIXT 4 # $67
TOTALS: $275.00
Mech. Plan Check Plumb.Plan Check Elec. Plan Check 0.0 1 hrs $0.00
Mech. Permit Fee: Fp
ch. Permit Fee: Elec. Permit Fee: IEPERMIT
Other Mech.Insp. Other Plumb Insp. Other Elec. Insp. 0.0 hrs $45.00
.%Iech.Insp. Fee: Plumb. lnsp.Fee: Elec. insp. Few:
NOTE: This estimate does not includejeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Setter District,School
District, etc.). Thesefees are based on the prelintinari information available and are only an estimate. Contact the De t or nrldn'I info.
FEE ITEMS (Fee Resolution 11-051 E2 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
SuPP1. lisp Fee
PME Unit Feer $275.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: 1,4WHN $42.00
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $45.00
i
Sarong Motion Fee: IBSE/SMICR $0.50 Select an Administrative It
131dg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $408.50 $0.00 TOTAL FEE: $ 8.50
Revised: 10/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408'777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: Z tS $DO POLc> e- — ERMIT#
OWNER'S NAME: Kt PHONE#
GENERAL CONTRACTOR: rSS E`r�, BUSINESS LICENSE #
ADDRESS: ..p 3 33Z CITY/ZIPCODE: 0z-- O !^� S'3
*Our municipal code 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 CUPEWI'INO
BUSINESS LICENSE.
am not using any subcontractors: _ 7-/Z
Signature Date
Please check applicable subcontractors and complete the following information:
V. 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