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12120090CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 303D CONTRACTOR: BAY AREA ENTERPRISE PERMIT NO: 12120090 OWNER'S NAME: JOHN DZURKO 2110 MANGIN WAY DATE ISSUED: 12/18/2012 OWNER'S PHONE: 6509490118 SAN JOSE, CA 95148 PHONE NO: (408)238-5043 ❑ LICENSED CONTRACTOR'S DECLARATION F License Class 1 Lic. # C� (q V —1p BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH F_ RESIDENTIAL r— COMMERCIAL .n Contractor Date 174 1 -S l �t ;-- I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: UNIT 303D - REMOVE AND REPLACE SHOWER VALVE (commencing with Section 7000) of Division 3 of the Business & Professions AND CLEAN UP SURROUNDS 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 Sq. Ft Floor Area: Valuation: $3000 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 34253088.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the Ci of Cupertino against liabilities, judgments, costs, and expenses which may acc against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. A i 'on al , the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source g lat' s per the Cupertino Municipal Code, Section 9.18. l M Il Signature Date i� Issued by: ��/1� �,�j�f� Date: ❑ OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for 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 I, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: 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 BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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 Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25,9#2(a) should I store or handle hazardous material. Additionally, should I equipment or devices which emit hazardous air permit is issued. contaminants as define by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued, I shall maintain complian th 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 Health & Safe d ections 25505, 25533, and 25534. 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 Owner ri d gent: Date: forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION CONSTRUCTION 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 laws 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 property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION 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 CIJPFRTtNA CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buiiding(cDcupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION L_�7 ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS C`- i u I it I` C N# 2 g !�' OWNER NAME Ci K /� ` r PHONE f`/ E-MAIL rG i iA ; -4 Z c/�['�IC it ll r7 rig ' {�'t� _1 y rl C /l li'Y�' STREET ADDRESSZ l L C r j J �O 7 i CITY, ST �EC IP ` ' G' Ic FAX c` �4 CONTACT NAME r,l� PHON�r� �. 4,- c f/' E-MAIL STREET ADDRESS 2 /l © / L✓` CITY, STATE, ZIP �� FAX �fG61 e�i ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICE �JMBfsR LICENSE TYPE BUS. LIC # Jl . I 7� COMPANY NAME E-MAILFAX G� CCG ,�1�c�Gi t � �C�" • �'f �� ,�'�•�, �� i G' i�i Sf ,- C-Cs'�1 STREET ADDRESS CITY, STATE, ZIPS `S - C ;:q �s-� U� PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK c EXISTING USE PROPOSED US CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET BATHROOM KITCHEN REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOT ORCH AREA I GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: S A SECOND UNIT []YES SECOND STORY ❑ YES BEING ADDED? ❑NO ADDITION? []NO PR.E-APPLIC&r6N ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEI i'TOTAL VALUATION: PLANNING APPL # [-]NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO 31 31i, 74 "G By my signature below, I certify to each of the following: I am the pro erty owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I ave rea Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construct] n. author' representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of ApplicanUAgent: Date: SUPPLEMENTAL INFORMATIO Q IRED""" M` A c PLAN CHECIZ.TYPE .. F �a�... ROUTING„SL ,,V .;�, e f New SFD or Multifamily dwellings: Apply for demolition permit for OVER -T Uu� aE courtTE>t s7NGPLnI REVIEW existing building(s). Demolition permit is required prior to issuance of building r t permit for new building. EXPIiEssLAN REVIEw� _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD PUBLIC WORKS ` form if any Hazardous Materials are being used as part of this project.k£ _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR SANrfARY SE1i'ER DISTRICT , submittal of Building Permit application. k h - ENVIRONMENTAL; HEALTH'�< .... ;c BldgApp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 23500 Crito Rey Dr DATE: 12/18/2012 REVIEWED BY: Sean UNITS APN: BP#: "VALUATION: 1$3,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex # PENTAMATION 1 RPFIX PERMIT TYPE: 19 WORK Unit 303D: Remove and replace shower valve and clean up surround. SCOPE Supp/. Insp Fee APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES Fee: Fixture or Trap 1BPFIXTURE or/,"",Li 1 # $10 1'erinit .Fee: Supp/. Insp Fee PME Unit Fee: $10.00 PME Permit Fee: $45.00 C,'c�tl.Sll lrCt1W7 7'M'.' Administrative Fee: ]ADMIN $42.00 Work Without Permit? 0 Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $10.00 Strong Motion Fee: 1BSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the prelimina information available and are only an estimate Contact the De t or addh7 info. FEE ITEMS (Fee Resolution 11-053 U f 7/1112) t.f<, ch. Plan C `Inf,( k Plumb. Plan Check 0.0 hrs $0.00 /,`ut . t l w Chcxk Plan C'hcc k Plumb. Permit Fee: IPPERMIT Fee: C)i wv hies h, Iasi).F-1 -L- Other Plumb Insp. 0.0 hrs $45.00 or/,"",Li PME Plan Check: $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the prelimina information available and are only an estimate Contact the De t or addh7 info. FEE ITEMS (Fee Resolution 11-053 U f 7/1112) FEE QTY/FEE MISC ITEMS Plan C'hcc k Su pl. PC.' Fet, PME Plan Check: $0.00 1'erinit .Fee: Supp/. Insp Fee PME Unit Fee: $10.00 PME Permit Fee: $45.00 C,'c�tl.Sll lrCt1W7 7'M'.' Administrative Fee: ]ADMIN $42.00 Work Without Permit? 0 Yes 0 No $0.00 r1C.lValleed Plarming Fees: Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $143.50 $0.00 TOTAL FEE: 1 $143.50 Revised: 10/01/2012