12110158CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNfT 203E CONTRACTOR: MISSION VALLEY PERMIT NO: 12110158
ELECTRIC INC
OWNER'S NAME: FLORENCE MANN PO BOX 3332 DATE ISSUED: 11/30/2012
OWNER'S PHONE: 6509440100 FREMONT, CA 94539 PHONE NO: (510) 745-8847
9l LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r
License Class — I d Lic. M `7 ?d 19
Contractor Date / f --a&>
I Z
1 hereby a rrm 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.
I 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 so gulati s per the Cupertino Municipal Code, Section
9.18. �
Signature Dated Z
❑ OWNER -BUILDER DECLARATION
I 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).
I 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
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, after making this certificate of exemption, l
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. 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 accme 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.
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: 203E - 5 LED LIGHTS, 12 SWITCHES, 20 RECEPTICLES
Sq. Ft Floor Area: I Valuation: $2500
APN Number: 34253073.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LMT CALLED INSPECTION.
//(
Issued by: /L'/A "/ ,301" Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material beug installed. If a roof is
installed without first obtainin inspection,1 agree to remove all new materials for
inspection.
r _
Signature of Applicant: D te:
I/I�o-/;
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. 1 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 concoction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 7773228 • FAX (408) 777-3333 • buildina8cuoertino.ora
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USE OF ❑SFD) DuFLEX K_MULTI-FAMILY
PROJECT IN WI DIAND ❑ YES
PROfECTIN YES
IS THE BLDG AN ❑YES
BURRING: ❑CRMMERCIAL
URBAN INTERFACE AREA ❑ NO
FLOOD ZONE ❑ NO
ECHI.ER HOME'. ❑ NO
DESCRIPTION OF WORK
TOTALVALUATION:
RECEIVED BY:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have
d is correct have read the Description of Wark and
verify it is accurate. I agree Io comply with all applicable local
ordinances and state laws ,,an m di
onstrueti authorize representatives of Cupertino
:e enter the above-identi5edprope.—i for inspection purposes.
Signature ofApplicantlAgent
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Date: '3 •i '�—
SUPPLIMfENTAL
INFORMATION REQUIRED
OFFICE USE ONLY
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ME'PMLrcApp_2011.doc revised 06/21111
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CITY OF CUPERTINO
I ENE FEE ESTIMATOR — BUILDING DIVISION
APPLIANCE/EQUIP TYPE
ADDRESS: ZO$b0 C►Z)S-fO Y`- DATE: 11/30/2012
REVIEWED BY: larrys
QTY
APN: BP#:
`VALUATION: Iso
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
Elea Insp. 0.0 hrs $45.00
PENTAMATION 1REAP10
USE:
$113
PERMIT TYPE:
WORK
5 led lights, 12 switches 20 rete titles
SCOPE
APPLIANCE/EQUIP TYPE
FEE ID
i'[unri�. NL„, Clur�d�
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Recep/Switch/Outlets
1BREMRECEP
Elea Insp. 0.0 hrs $45.00
37
#
$113
i',v-,nir Frr.
.�opp!lr,.q, l :,c
PME Unit Fee:
$113.00
PME Permit Fee:
$45.00
(OHINWI!m!.' to
Administrative Fee: IADMIN
$42.00
Work Without Permit? O Yes Q No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$113.00
Strong Motion Fee:
NI l t i
!.•. �, i:.,,, t';,,,. �.-
i'[unri�. NL„, Clur�d�
Elec. Plan Check 1 0.0 hrs $0.00
Nr<n PC ,il kc'c
Plualb. 1''crwir t=..-:
Elec. Permit Fee: IEPERMIT
1, ,p /n.,p
o,hrr l7„n,h Inv, E—jOther
Elea Insp. 0.0 hrs $45.00
,•;'L l;r,I. i.,.:
I'lund, F'be'
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NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etrA These feet are hated an the nreliminam information available and are on/v an estimate. Contact the Devi for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Efl' 7/1112)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
i',v-,nir Frr.
.�opp!lr,.q, l :,c
PME Unit Fee:
$113.00
PME Permit Fee:
$45.00
(OHINWI!m!.' to
Administrative Fee: IADMIN
$42.00
Work Without Permit? O Yes Q No
$0.00
/)lilt ,A('Prl /�iUfllEf i';� 1'Pi?S:
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee:
$0.00
Select an Administrative
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$245.00
$0.00 TOTAL FEE:
1 245.00
Revised: 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: Cz4
- PERMIT #
OWNER'S NAME: dt:'2. e>:3 -
PHONE #
GENERAL CONTRACTOR: kl V
BUSINESS LICENSE #
ADDRESS:P/9.
CITY/ZIPCODE: 9� i _
*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 BCON I CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information:
ll- 3a-1 2,
Date
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