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11030009CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR UNIT OFFICE CONTRACTOR: FANTASTIC BAY PERMIT NO: 11030009 BUILDERS INC OWNER'S NAME: THE FORUM RANCHO SAN ANTONIO 675 E GISH RD DATE ISSUED: 03/02/2011 ER'S PHONE: 6509440100 1 SAN JOSE, CA 95112 1 PHONE NO: (408) 647-4010 ❑ LICENSED CONTRACTOR'S DECLARATION License Class C3C, Lic. # Contractor ;c to 3 I hereby affirm that I am license 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 ke harmless the City of Cupertino against liabilities, judgments, costs, and expen a which may accrue against said City in consequence of the granting of this a it. Additionally, the applicant understands and will comply with all non -p nt ource reguI i s per the Cupertino Municipal Code, Section 9.18. Signatur Date Li OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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 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 nify and keep harmless the City of Cupertino against liabilities, judgments, 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. Signature, Date BUILDING PERMIT INFO: BLDG I— ELECT f— PLUMB r MECH i RESIDENTIAL f— COMMERCIAL F JOB DESCRIPTION: REPLACE TWO EXISTING FLOOR SINKS, USE 8X8 IN. SINKS MOUNTED FLOOR LEVEL Sq. Ft Floor Area: I Valuation: $200 APN Number: 34254999.00 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: Date: 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) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air conta 'nants as defined by the Bay Area Air Quality Management District I will main acompliance ith the Cupertino Municipal Code, Chapter 9.12 and the Hca h & Safety C94 JSections 25505, 25533, and 25534. or author ag goDate: 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34254999.00 DATE ISSUED.......: 03/02/2011 RECEIPT #.........: BS000012800 REFERENCE ID # ..-: 11030009 OPERATOR: patg COPY # : 1 SITE ADDRESS .....: 23500 CRISTO REY DR UNIT OFFIC SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: THE FORUM RANCHO SAN ANTONIO ADDRESS . 23500 CRISTO REY DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: LEON E GARDERE CONTRACTOR .......: CHARLIS YOUNAN LIC # 32301 COMPANY ..........: FANTASTIC BAY BUILDERS INC ADDRESS ..........: 675 E GISH RD CITY/STATE/ZIP ...: SAN JOSE, CA 95112 TELEPHONE ........: (408) 647-4010 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 200.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BPFIXTURE NO OF FIXTURE 2.00 16.00 0.00 16.00 0.00 1BSEISMICR VALUATION 200.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 0.00 TOTAL PERMIT ---------- 101.50 ---------- 0.00 ---------- 101.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 101.50 --------------- 101.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 512 FINAL HANDI-CAP CITY OF CUPERTINO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM APN�, q Fee ID Date: .3. Z.. I Building Address: Permit Type Owner's Name: ,x4^1-{-� 1PCSEWER one #: 64-0 F� � — 4/0 0 Contractor: f NTr9S�iL 6' 1CPSS Phone #: /-log_ 5tf-30q�- �.1F/VG: Commercial re -pipe per fixture Fax #: Contact: C R i s \ c� N Phone #: Z61,7� P Fax/e-mail: Contractor License #: 7'13 --�Z- 1BCBSC Cu ertino Business License #: B // Job Description:40,A.Ae & �w rXe eI't, S 'Al's S - R-PL04:- ' PiX) S -1 fV1t- � Z 5100- Gy, �t fiYIS`GV TI 10.4 L/o- L6'. F 0( Rr � S)N 4R p Wor- L-I;-VrL- P Residential ❑ Commercial Valuation: �Q,� ..... Project Size: Counter ❑ Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points: Quantity , Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial building sewer/sanitary sewer P 1CPSS 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System 1-4 Outlets P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial P Revised 12/06/10