12120092CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 316D I CONTRACTOR: BAY AREA ENTERPRISE I PERMIT NO: 12120092 I
OWNER'S NAME: ALLAN KOBLICK
2110 MANGIN WAY I DATE ISSUED: 12/18/2012
OWNER'S PHONE: 6505371523 I SAN JOSE, CA 95148 I PHONE NO: (408)238-5043.
❑
CENSE D CONTRACTOR'S DECLARATION
�
License Class Lic. # ` I
Contractor Date 1 "L �sdui
I 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.
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.
I certify that I have read this appli ation and state that the above information is
correct. I agree to comply with al ity and county ordinances and state laws relating
to building construction, and her y authorize representatives of this city to enter
upon the above mentioned propefy for inspection purposes. (We) agree to save
indemnify and keep harmless th City of Cupertino against liabilities, judgments,
costs, and expenses which ay crue against said City in consequence of the
granting of this permit. A iti Ily, the applicant understands and will comply
with all non -point so ce g ions per the Cupertino Municipal Code, Section
9.18. )
Signature Date
❑ 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)
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:
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.
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, 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
1 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.
BUILDING PERMIT INFO: BLDG f— ELECT f— PLUMB i
MECH I— RESIDENTIAL F COMMERCIAL f—
JOB DESCRIPTION: UNIT 316D - REMOVE AND REPLACE SHOWER VALVE
AND
CLEAN UP SURROUND
Sq. Ft Floor Area: I Valuation: $3000
APN Number: 34253095.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: G !% Date:,/, --7 j 'fir
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
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) sho Id I store or handle hazardous material.
Additionally, should I use equip nt or devices which emit hazardous air
contaminants as defined by the #y Area Air Quality Management District I will
maintain compliance v4th the fupertino Municipal Code, Chapter 9.12 and the
Health & Safety CodeySectioqk 25505, 25533, and 25534.
Owner or h Tent:
Date:L--
IJ
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of %ork's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date I Licensed Professional
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - building(cDcupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS
it",` -,IV � D9- 3i(�
APN #
� 2 S 3- �'�'�
23500
OWNERNAME
l< 1,�i�
PHONE _ f7 !'— l 3
�> 7
E-MAIL
1
4501
STREET ADDRESS �'� �1G
CITY, STATE, ZIP
FAX
CONTACT NAME J
PHONE t ." 23�'_
E-MAIL 1
(�� 4r SI�CF!y�
STREET ADDRESS
CITY, STATE, ZIP
AX
`
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMEc
LICENSE NUMBER
LIC SE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP �__ / y
PIO��: -3 g.
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE PROPOSED USE CONSTR TYPE # STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET
BATHROOM
KITCHEN
O
REMODEL AREA
REMODEL AREA
ODEL AREA
PORCH AREA
DECK AREA
TOTAL ORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
#DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? []NO
ADDITION? []NO
PRE- CATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AN E] YES
RECEIVED
TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
&
--
By my signature below, I certify to each of the following: I am the property owner or 'thorized age t to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Des. ipti of Work and erify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize repr tiv s of Cupertino o enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATIONREQUIRED\
_,,PLAN:
k kn k
New SFD or Multifamily dwellings: Apply foremolition permit for
_
OVEII TH&COUNTER
{'
BUILDING PLAN REl'IEW
ance of building building(s). Demolition permit is required prior to issu
permit for new building.
EXPRESSs �`
fl PLANNINGPLANREVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
�T,* W4 E
Q sTAIVDpItD u
fl JPu Ll WpRxs y
_
h ,
form if any Hazardous Materials are being used as part of this project.
h ��
N h�
_ Copy of Planning Approval Letter or Meeting with Planning prior to
d SEWER
submittal of Building Permit application.
MAJOR
SANrfAR] DISTRICT t a.'
4
,'O ENVIRONMENTAL HEALTH> 3
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FM -7 FEE ESTIMATOR -BUILDING DIVISION
im,ADDRESS:
23500 Crito Rey Dr --7DATE:
12/18/2012
REVIEWED BY: Sean
UNITS
APN:
BP#:
'VALUATION: 1$3,000
PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPFIX
PERMIT TYPE:
WORK
Unit 316D: Remove and replace shower valve and clean up surround.
SCOPE
suppl. 11tsp Fe"
APPLIANCE / EQUIP TYPE
FEE ID
Plan Check 0.0 hrs $0.00
QTY
UNITS
BP FEES
t;lr.c. Permit Vice
Fixture or Trap
1BPFIXTURE
Oih(- f lee. Inst:. F-1
1
#
$10
Permit Fec
suppl. 11tsp Fe"
PME Unit Fee:
$10.00
PME Permit Fee:
$45.00
C:'nrzStrrrction Tcr_a-:
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes (E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$10.00
Strom Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District etc.). These fees are based on therelimina information available and are on1v an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7iI!12Z
Vfcch. t'lau t'hcc:kEPlumb.
Plan Check 0.0 hrs $0.00
f"1��s,_ 1'kat� C`dz ick
11('ch. Permit
Plumb. Permit Fee: IPPERMIT
t;lr.c. Permit Vice
Onccr ,ta`cch. lisp.F-1 -L---
Other Plumb Insp. Elhrs $45.00
Oih(- f lee. Inst:. F-1
:1(t�c/z. ln.it�. /��e:
1'hartth. I� s1�. J•Frr:
1:`lec. Insp. f��ze_
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District etc.). These fees are based on therelimina information available and are on1v an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7iI!12Z
FEE
QTY/FEE
MISC ITEMS
Plan CtYcc/` Fee:
Suppl. 1'(1' Fees
PME Plan Check:
$0.00
Permit Fec
suppl. 11tsp Fe"
PME Unit Fee:
$10.00
PME Permit Fee:
$45.00
C:'nrzStrrrction Tcr_a-:
Administrative Fee: IADMIN
$42.00
Work Without Permit? 0 Yes (E) No
$0.00
"Idvar ccd Planning I°rrc, ,
Travel Documentation Fee: ITRA VDOC
$45.00
Strom Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$143.50
$0.00 TOTAL FEE:
$143.50
Revised: 10/01/2012