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14090116 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23600 VIA ESPLENDOR CONTRACTOR:MISSION VALLEY PERMIT NO: 14090116 ELECTRIC INC OWNER'S NAME: ROMAN CATHOLIC BISHOP OF SAN JOSE, PO BOX 3332 DATE ISSUED:09/18/2014 OWNER'S PHONE: 6509440100 FREMONT,CA 94539 PHONE NO:(510)745-8847 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL / INSTALL FOUR(4)NEW 20 AMP CIRCUITS IN KITCHEN License Class -1 Lic.# y 7 L 7- AT Contractor MiSS/D,JUAB 6jfig r—Date �} —� �— ( `� HEALTH CARE FACILITY 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. Sq.Ft Floor Area: Valuation:$2500 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 APN Number:34254016.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WI 80 D IT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 D OM L LLED INSPECTION. 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. dditionally,the applicant understands and will com Issued b Date: with all non-points rce regulations er the Cupe ino Municipal Code,Section 9 18. ' p RE-ROOFS: Signature Date 6 -�y 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the C ertmo M mcipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 25 05,255 ,and 2553 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized Date: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9 18. Signature Date GENERAL PERMIT APPLICATION NA I E P COfAMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 T ORRE AVENUE• CUPERTINO, CA 95014-3255 (408) 777-3228•FAX(408)7777-3333-buildingecuDetno.ora j�,v MISl ❑PLU7✓,3I1vG ❑2`^tCtii?KIC.SLE F—CTRICAL ❑AuSCELLAI�sOUS PROTinCI'ADDP.ES� O LzF o�.n.�7�AJ,�� C'►4TIt�L t G �is�� I P��SI> -01 -O 6f� I =.7✓t.IL STzRZET ADDRESS I CITY, STATE,ZIP.. I FAX CON-7ACT NAtr ; I PiOhB I B-1✓kT� STRZ i ADDRESS CITY,STATS ZIP I FAX OWh .❑ o-A-=?,.BLu.D=m ❑ OJrh-R ACTT Co\-,R-ACTOR 13CO2\-m4CT0RACh- ❑ lu?Cm—mCT ❑"�'NM ❑ 1)1-'LO?ZR. ❑ i=NAT'S CGI4TRkCTORN LICr'hSBNUbrER L7CD- ,SETYPB B US.L7C� 1 I --SZ I G— col�r�a�I� Lam°n I 61 r�.3 zZ6- 62 STP:=ADDRESS L C I . i ,STATr,Z G� �� I MONS 4 TTY Z d �RCFuT� Gam_RNA1J ; I LICENTSENU SER BUS.LIC CON,MYNANS B-W�A.JL I FAX STRn'«T ADDRESS I CITY,STATE,ZIP PHONE. USE OF ❑SPD or DUPLEX ❑ MJLTI-FAMLY I PROj-&=LN WIIAL 11\m ❑ -as I PROJECT WT ❑YES I IS T-F-BLDG AN ❑1 S BUII.DrRG: ❑coN�,CLSL ARBA ❑ NO FLOOD? I'm ❑NoEICs.r'RHOI•r7 ❑ No DEM.IPTION OF WORK �� s ZOO, I 0-mm imam �1 rF kF� Yom. TOTAL VP TUA.-DON: By ny signature belov4,I cer:L"y to eacb P�,i�-?.nstructiom 011m ring: I am u7e property owner Or all hor iz'd agent to act on tine propel i o,,Z-3e -- cVt read this application and the infozatioa I h e pis correct I we read the Description of Work and veay it is accu-ate. I a_*ee to cernply u2�h all zpplicable local ordinances and state 1a„s relating to uthoriu representa�v^ f Cupertino to eater rhea ove-identified orope y for i^specaon purposes. e � Signaure of Apalicz,J.rgeat: Date; f SL PAN PLE_ NTAl L?�-0 Tk CATION DoFcEsz = —_- d 7 S 1✓EPA 'sc pp_2011.doc r evised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 23600 via esplendor DATE: 09/18/2014 REVIEWED BY: Mendez APN: BP#: *VALUATION: 1$2,500 rPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP USE: PERMIT TYPE: WORK INSTALL four 4 NEW 20 AMP CIRCUITS IN KITCHEN AT HEALTH CARE FACILITY SCOPE 3 < S /<-rrr. Pion(` <r'k 1'Itar,,I>. Plrrrt(.:'heci; Elec.Plan Check 0.0 hrs $0.00 F/.(.b Pe°r•nrit f=ee: Plumb, Permit l�'ee: Elec.Permit Fee: IEPERMIT Other Plurnh 7mTr- Other Elec.Insp. 0.0 1 hrs $48.00 {,z.>ra IizslJ, f ru: f.'({:{. In so NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/11131 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Electrical Suppl. PC Fee: (j) Reg. 0 OT 0.0 1 hrs $0.00 $143.00 IBREMMISC Apparatus PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. ® OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $48.00 Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes (F) No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential G Travel Documentation Fee: ITRAVDOC $48.00 Building or Structure i Strang Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $142.50 $143.00 TOTAL FEE: $285.50 �e Revised: 08/20/2014