12110160CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 303D CONTRACTOR: MISSION VALLEY PERMIT NO: 12110160
ELECTRIC INC
OWNER'S NAME: JOHN DZURKO PO BOX 3332 DATE ISSUED: 11/30/2012
OWNER'S PHONE: 6509440100 FREMONT, CA 94539 PHONE NO: (510) 745-8847
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class ' t D LicA t--1 2 d % 3 Z
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 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.
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 soyreg regulations per the Cupertino Municipal Code, Section
9.18.
(- S p -I Z
❑ OWNER -BUILDER DECLARATION
1 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following 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.
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
permit is issued.
1 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, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I most
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. 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.
Date
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: 303D - 5 LED LIGHTS, 12 SWITCHES, 20 RECEPTICLFS
Sq. Ft Floor Area: I Valuation: $2500
APN Number: 34253088.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAt�77r
T CALLED INSPECTION.
Issued by: Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining a 'n pec ion I agree to remove all new materials for
inspection.
Siginiture of Applicant: Date:
(. _u - 1
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
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 by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
CONSTRUCTION LENDING AGENCY
I hereby affirm that 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
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 950143255
(408) 777-3228 • FAX (408) 777-3333 - building(E)cuoertno.orD
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ARCHITECT/ENGINEER NAME
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CITY, STATE, ZIP
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115E OF 0 S m DUPLEX Ok MULTI-FAMB.Y
BUILDING ❑COMMERCIAL
PROIFLTPN WIDLWD ❑ YFS
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
ISTHEBLDGAN ❑ YES
flC1n.ER HOME! ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION: ys—/rw
RECEIVED BY:
By my signamrc below, I certify to each of the following: I am the property owner or authorized agent to act on the property Owner's behalf. Il have read this
application and the information I have provided is correct I e read the Description of Work and verify it is accurate. I agree m comply with all applicable local
ordinances and state laws relating conb'nttcom I ori= represenmtives of Cupetd:s :c enter the abo idFnn ;dprype,—j for inspection V4poses.
Signature ofApplicant/Agmt Date: _ S (�.•
StPPLEKONTAL
TIO QIJME'D
OFFICE USE ONLY
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❑ STANDARD
❑ LARGE
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M-PffucApp_101 Ldoc revised 06121111
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APPLIANCE / EQUIP TYPE
�aa a
FEE ESTIMATOR
va '. - a,aaau.v /�
BUILDING DIVISION
QTY
ADDRESS: z3511a �)TM 6LeDATE: 11/30/2012 REVIEWED BY: larrys
BP FEES
APN-3g2,,53-10$ BP#:
`VALUATION: $0
"PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or DU lex
p
#
$113
PENTAMATION 1 REAP10
USE:
PERMIT TYPE:
WORK 15
led lights, 12 switches 20 rete titles
PME Unit Fee:
SCOPE
PME Permit Fee:
$45.00
APPLIANCE / EQUIP TYPE
FEE ID
Plum/, Fhe,r (hcrr,
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERM/T
Recep/Switch/Outlets
1BREMRECEP
Other Elec. Insp. 0.0 hrs $45.00
LI
37
#
$113
P.. .,. .
PME Unit Fee:
$113.00
PME Permit Fee:
$45.00
17-
Administrative Fee: !ADMIN
$42.00
Work Without Permit? O Yes O No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$113.00
Strong Motion Fee:
NOTE. This estimate does not include fees due to other Departments (I.e. Planning, Public Works, Fire, Sanitary Sewer District, School
f1hi,iel etc ) Thoso foot are hated an the nreliminam information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS p-ce Resohdion 11-053 Eff 7,1/122
FEE
Plum/, Fhe,r (hcrr,
Elec. Plan Check 1 0.0 1 hrs $0.00
41-r:
Plumf,. 1'v7 vw F,-:
Elec. Permit Fee: IEPERM/T
,
nrm.,,f•17-
Other Elec. Insp. 0.0 hrs $45.00
LI
Plumbb,,P l',,,-
6'r•; hxy 1..
NOTE. This estimate does not include fees due to other Departments (I.e. Planning, Public Works, Fire, Sanitary Sewer District, School
f1hi,iel etc ) Thoso foot are hated an the nreliminam information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS p-ce Resohdion 11-053 Eff 7,1/122
FEE
QTY/FEE
MISC ITEMS
.to, � ;rc•rlr.. x,.
,
PME Plan Check:
$0.00
P.. .,. .
PME Unit Fee:
$113.00
PME Permit Fee:
$45.00
17-
Administrative Fee: !ADMIN
$42.00
Work Without Permit? O Yes O No
$0.00
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee:
$0.00
Select an Adminis i e
Bldg Stds Commission Fee:
0,90
SUBTOTALS;•
$X5.000
I,-e.00
TOTAL FEE:
1 $245.00
L� Revldd: 10/01/2012
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: Z 3SD G 5
Q IPERMIT#
OWNER'S NAME: v fLJ _V=
30 3 "-':> IPHONE#
GENERAL CONTRACTOR: hISSt .S ✓
FcrzTRtc- BUSINESS LICENSE #
ADDRESS: R O. &P X 3S3 Z
CITY/ZIPCODE: -Cw.e 'i Vi
*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 CONT CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: -s
Signat a 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