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14100030M CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 406F CONTRACTOR: MISSION VALLEY PERMIT NO: 14100030 ELECTRIC INC OWNER'S NAME: LARSON CARL V TRUSTEE & ET AL PO BOX 3332 DATE ISSUED: 10/06/2014 OWNER'S PHONE: 6508514887 FREMONT, CA 94539 PHONE NO: (510) 745-8847 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL INSTALL (11) LED LIGHT FIXTURES; (6) SWITCHES; (2) License Class '''%' Lic.. # Y 7� Z EXHAUST FANS; (4) CABINET LIGHT FIXTURES. , / Contractor I _ o 51,, j V A&1 �-� tea- Date 1,5-4 — 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 Sq. Ft Floor Area: Valuation: $6000 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 APN Number: 34253173.00 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 WITHIN 180 DAYS OF PERMIT 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 DAYS FROM LAST CALLED 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 v C granting of this permit. Additionally, the applicant understands and will comply Date: �� Issued by: 7 with all non- ointa regulations per the Cupertino Municipal Code, Section 9 18. ��telQ RE -ROOFS: Signature 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 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) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (See.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 er 'no Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Section 5 , 25 3, and 25 4. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: e Date: / permit is issued. — — — — — — 7— 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 ION COMMUNITY DEVELOPMEMNT DEPARTMENT • BUILDING DIVIS101•: i0300 TORRE AVENUE - CUPERTIND, CA 95014-3255 (408) 777-3228 - FAX (40S) 777-3333 - build! ng. cuoerfino.gra m I S rInTTs,:rznvs I7T.=r;-7A1,--,r4T_ NSI+. C772_iCAL (73,g;CELLAh OL'S 1V, --j'Phlw�cfop_2011.doc revised 06/21/11 PaG�Z`LELS�t3 ��6 I <�NR 3, 73 v o v S —, ADD, ESS I CL i 1 c> t ` � - � 4-: 1F- CO2, --RCT )WS- I P70 I 1J_an STR-=1>D?u_qg I CTY,5i.4-, Zip 13 an,= .0 OWIc,- -n=ML❑ 03il� AGBA? CO? ?4C OR ❑ COAi� 4CTOP.AC?T ❑ c?C_: CT ❑ D C-? ❑ D1%= OP? ❑ ^`L� I C n� 4CT0}22�RiJ+. -ra 1 LC�SH lvUl�� I dt32 i.IC�SE �' I C—l� 3uS. LIC r N 0 SSId V l L �tt� lG I 2�t, *'z uss,o� Jo., -cam t�- i,: 45 I Sly Z -2-6 1 Z S 1 Z RDD?' �, �3z,- CITY i AT:, ZIP tip- �°�� S PHOhL 51©--2ys- 49- (V �i�. T-iCr'NSE hL7,�E8 I BUTS. LIC ig CONLflRI.TYI�T41ri- I Fi1Ji4II I FAX S ?.zcT ADDP,ESs I CITY, STAT -r, ZIP I PHOS USE 0_ ❑ .sm or DjpLzx ❑ NTJLTI-mz LY PROTECT W W1LDLAND ❑ YES I PROMECT W ❑ YrS I IS T:= BLDG AN ❑ S BL TILT G ElCO} ' CL4L 13RB i?� ATcR'rAG ARBA NO I Z.00D Z02,=- WO BLG.L=- 302YE? ? O DES O 'r ''D 1 /J`i —%1 Lam_ _ _ LGA SS (� 1 X i�1 -5- i�-IJZ� JE' l� 1'L Y2 ,:�' 'I YN— . TOTFT V I DATION: +-1�•�r. _ice' ...a;�sY YG �": .fix".+-�:C��' _ _ �•p,_i By �y _tom u e belo;a, I ce .ry to each o= ` follo;ving ha e re d this I am the pro -j o:;mer or av l o;;z^d agent to act on the proper y o,; Ler s bel alf. I : a; _ y a ar;alication and Lhe iniorrraton I have Ovid is coryact I have r d the Descr?Poon of v%ork and ve—. y it s aCVZF I a_*ee to com I v�L� all F o licahle local O: QIi]aaaeS and s`wie L --:;'s relating t oma co*vu.Ictio, I au_hor.=.. -epresen:ative •�ps;tino to eater tine above ider_ried proPle,.�� for i^specaen Pu�oses. S I gnatlre or : _PPUc�,t; :peat: S - uq PT -t— NTA! LNr _) Lk 10N R E Q fj=-D ..�� �f 1V, --j'Phlw�cfop_2011.doc revised 06/21/11 aU �9"�K - AT RANCHO SAN ANTONIO This Set of ala: AkHHHOVED ecif!catnns t.tliST be kept at the ob site dUr :.r ,r JClion. itis un p changes or ia`o"U to make any ItO. .bons on same, or to deviate therefrom, t�✓,;n,.; , approval from the Building Official. The Stamping of ,; plan and Speci "cations SHALL NOT be held to permit or to be an approval of the violation Bany provisions of any City Or inance or State Law. DATE tel` G •lo •jv Mode11)T # e 090 Square Feet Two Bedrooms e Two Baths Floor plans are representative. Actual measurements and layout may vary. Rev 10/10. BALCONY SPACE 110 Square Feet