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15040164I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 325F CONTRACTOR: OWNER'S NAME: KEALHOFER, SUSAN H TRUSTEE ASSIGNEE PERMIT NO: 15040164 DATE ISSUED: 04/22/2015 OWNFiR'S PHONE: 4152699310 I , I PHONE NO: I LICENSED CONTRACTOR'S DECLARATION License Class C- Lic. # 3 !��`% Contractor ( C1Tn %2r� ��PcT/7iG Date —/— 22-15 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. 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 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-p94W§65`r_c-eyegulations per the Cu ino Municipal Code, Section 918. Signature Date ❑ 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) I, 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 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ UNIT 325F - INSTALL 6 RECESSED LIGHTS IN LIVING RM Sq. Ft Floor Area: I Valuation: $1800 APN Number: 34253146.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN Issued by: ISSUANCE OR 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 contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the C Municipal Cod hapter 9.12 and the Health & Safety Code,ySe in 25505,33, an Owner or authorized agent: r -4--e > Datc: not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY 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 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 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 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 918. Signature Date Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO GENERAL PERMIT APPLICATION 6� COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION I 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 O (408) 777-3228 • FAX (408) 777-3333 • buildingacupertino.org ❑ TCAT ELECTRICAL ❑MISCELLANEOUS MEP MISC LjrLUIVIB G MI CIiAN PROJECT ADDRESS % ^ _/v ( APN -2 _ I / J r �� All# OWNERNAME N �I - , �y , PHO E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME Ae 17 el/%� ! C ! PHONE �56 _96r _go 3 YJ E-MAIL STREET ADDRESS CITY, STATE, ZIP /l FAX ❑ OWNER ❑ OWNER-BBUUELDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Q// �f ` LICEf NUMBE LICENS TYPE BUS. LIC # COMPANY NAME /, �G%1rC E-MAIL FAXC STREET ADDRESSCITY, ry G STATE, ZIP o PHONE AR.CHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES ❑ IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO BUILDING: ❑ COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE NO DESCRIPTION OF WORK TOTAL VALUATION:I ffo VDb$., By my signature below, I certify to each following: I am the prope owner or authorized agent to act on the property owner's behalf. I have read this application and the information I e provide is correct. I have a e: ion of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relat' g t ui constructs orize represen tiof Cupertino to enter the above-id� hied property for inspection purposes. G Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATIOKREQUIREDcJcE usE oNI y x' r ,.fit^;r't` m tT r ,' SER THE COUNTER ' L'CTA � 3 k1E sTaxDARD 7 x o.Qi MEPMiscApp_MLdoc revised 06/21/11 ,��,�,�,�,�� CITY OF CUPERTINO FORM? TIFF. F.CTTM A TnR - RIAIDING DIVISION imlADDRESS: 23500 CRISTO REY DR 325 F DATE: 04/22/2015 REVIEWED BY: MELISSA 1'lctrt Check Fee: APN: 342 53 146 BP#: "VALUATION: 1$1,800 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Multi-FamilyDwellin USE: g Building is >3 Stories ® Yes ® No PENTAMATION 1REAP11 PERMIT TYPE: A WORK UNIT 325F - INSTALL 6 RECESSED LIGHTS IN LIVING RM SCOPE szppl. It sj_x Fee APPLIANCE / EQUIP TYPE FEE ID QTY UNITS BP FEES Fixtures, Lighting 1BREMFIXT 6 # $72 TOTALS: $72.00 Ifech, Plan Check _btech. Permit Fee: Other Mcch. Insp Vlech. Insp. Fee: Plumb. Plan Check Plumb. Permit Fee: Other Plumb Imp Plumb. hrsla. Tee: Elec. Plan Check 10.0 1hrs $0.00 Elec. Permit Fee: IEPERMIT Other Elec. Insp.EEI rs $48.00 f>lec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (t.e. riannmg, runic works, rtre, aamiary Jewer Lnstrwt, ocavvi --- ■ -a __ L- netimato_ Cantart the hent for addn'I info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS 1'lctrt Check Fee: suppl..P(:, Fee PME Plan Check: $0.00 1,crinit Fee: szppl. It sj_x Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Construction Tax: _F7 Administrative Fee: IADMIN $45.00 Work Without Permit? ® Yes (E) No $0.00 Advanced Planning Fees: Travel Documentation Fee: 1TRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 �16 E,u;�3� $214.50 aaNk =U' AL FEE: - $0.00 " "` ''' ' $214.50 Revised: 04/01/2015