15040165I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 218C
CONTRACTOR: TE PERMIT NO: 15040165
OWNER'S NAME: ALLISON GLADYS H TRUSTEE I I DATE ISSUED: 04/22/2015
nWNElk'S PHONE: 4152699310 I , I PHONE NO: I
LICENSED CONTRACTOR'S DECLARATION
LicenseClass �%U Li.. # 9-3
Contractor (c72d le-, r�c Date 1-f ' 2 2
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
,!�ection 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, judgaee��-
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comet
with all non- P sourcc gulations per the Cupe Municipal Code, Section
918. j /
Date Z�"- .-
❑ 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
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
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
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
UNIT 218C - INSTALL 7 RECESSED LIGHTS, 4 IN
KITCHEN & 3 IN HALLWAY
Sq. Ft Floor Area: I Valuation: $2000
APN Number: 34253048.00 I Occupancy Type: I
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18 F PERMIT ISSUANCE OR
1 RA D MfM.LAST CALLED INSPEC'?ION.
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 contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with thS-Cupertmo Municipa ode, Chapter 9.12 and
the Health & Safety Code, [o9s 2550)5, 25533, anAT5534.
Owner or authorized agent:
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
rel
L PERMIT APPLICATION
GENERA \6 MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION (�O
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255^V
(408) 777-3228 • FAX (408) 777-3333 • buildingacuperting g vJ misc
1ZT,I urr e T F1 MTS(-.RLLANEOUS
U YLUM7i1NLT
PROJECT ADDRESS
- n -
APN # (/ /
?3 I
,
OWNERNAME/ C\/� may/ // �%O�
PHONE /^ /r/�-���^�r1�O
-
J/
E-MAIL
STREET ADDRESS
CITY, STATE/
FAX
CONTACT NAME e /zf /
// !
PHONE �e SO T D6 ^ )63.1
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME /� �� (�
hll
LICEINUMBER
LICE�ET;PE
�,
BUS. LIC#
COMPANY NAME �+
E-MAIL
FAX
STREET ADDRESS 30/ ' / Z "1 j /-4- Q
CITY, STATE, ZIP cew /P el---lo7o
PHONE � le dq
ARCHITECT/ENGINEERNAME
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
)� / �+
O C_ �i�Ri.S .��/ �/Cfi� l i-,rs
�f �� ?qC
11a®0d.OU
TOTAL VALUATION: ? . 4' § ,.rt...,
By my signature below, I certify to mg: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the informatio av provided is rrect. I have read the n of Work and verify it is accurate. I agree to comply with all applicable focal
ordinances and state laws re ting buildin struction. uth represen tives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicant/Agen ;. Date:
SUPPLEMENTAL INFORMATION REQUIRED oFFcE usE oivLY = f
..
�� OVER THECOUNTER
W
r
STANDARD w, ?'017`
`
a y";
MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEW
:W FEE ESTIMATOR —BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 23500 CRISTO REY DR 218C
DATE: 04/2212015
REVIEWED BY: MELISSA
UNITS
APN: 342 53 048
BP#:
*VALUATION:
1$2,000
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Multi -Family Dwelling
USE:
Buildino is
1 >3 Stories ® Yes ® No
PENTAMATION 1REAP11
PERMIT TYPE:
WORK I
UNIT 218C - INSTALL 7 RECESSED LIGHTS 4 IN KITCHEN & 3 IN HALLWAY
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Fixtures, Lighting
1BREMFIXT
7
#
$72
Permit Fee:
Sup/)/. Ires llee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction :lax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? ® Yes (j) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$72.00
—
alech. Plan Check
hleclr. Penni, Fee:
C her .A,kch. €rasp.
,kleclz. Insp. Fee:
Plumb. Plan Check
Plumb. Permit Pec::
Other Plumb Insp.
Plumb. Insp. Fee:
Elec. Plan Check 10.0 1 hrs $0.00
Elec. Permit Fee: IEPERMIT
Other Elec. Insp. 0.0 hrs $48.00
Lslec_ Insp.
NOTE: This estimate does not include fees due to other Departments (i. e. Planning, Public works, Pire, sanitary Fewer District, Scnooi
71..f::nf o/n I Th.— foo. aro ha.od nn tho nroliminnn) infnrmatinn availahlo and aro anly an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 7�
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. l'(.1' Fee
PME Plan Check:
$0.00
Permit Fee:
Sup/)/. Ires llee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction :lax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? ® Yes (j) No
$0.00
Advanced Planning fees:
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
131da Stds Commission .Fee: IBCBSC
$1.00
1. �'
A a,
� i�
$214.50
7- 7,
$0.00 s,T� L�>E'•�
�n
$214.50
Revised: 04/01/2015