15040166CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 110C CONTRACTOR: ` -
PERMIT NO: 15040166
OWNER'S NAME: HARTINGER MARKS ELIZABETH TRUSTEE
DATE ISSUED: 04/22/2015
OWN 'S PHONE: 4152699310
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
LICENSED CONTRACTOR'S DECLARATION
UNIT 110C - INSTALL 4 RECESSED LIGHTS IN LIVING RM
q
License Classy C-16)Lic.
1; ,7,e Date —�-?` �J
Contractor ( o�
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:
and will maintain a certificate of consent to self -insure for Worker's
Cave
inas 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: $1200
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 34253019 00
Occupancy Type:
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
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
180 DAY '� CALLED IN77;�,
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
Date:
granting of this permit. Additionally, the appy t understands and will co
a
with all non- nt sou a regulations p e C rtino Municipal Code, S n
918.
Signature Date � /
RE -ROOFS:
All roofs shall bInspected 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,
do the work, and the structure is not intended or offered for sale (Sec.7044,
will
Business & Professions Code)
I, 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 Ba Area Air Quality Management District I
tino Municip e, Chapter 9.12 and
performance of the work for which this permit is issued.
will maintain compliance with a up
the Health & Safety Code, S ctio s 25 5, 25533, 534.
1 have and will maintain Worker's Compensation Insurance, as provided for by
for this
/�
7 _0Z?- 15 -
Section 3700 of the Labor Code, for the performance of the work which
Owner or authorized agent: Date:
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
Code, I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor must
work's for which this permit is issued (Sec. 3097, Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked.
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,
expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
costs, and
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
CUPERTINO
n
�D r
GENERAL PERMIT APPLICATION Q
MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingo-cugertino.org ` MISC
1-1.„ .,. .,..r I.FriarreT F MTS
. iCELLANEOUS
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �J/e 1 /
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LICENS 3 qB _
LICEN E TYP�
BUS. LIC #
COMPANY NAME
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CITY, STATE, ZIP
PHONE
ARCHITECT/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
❑ NO
BUILDING:❑ COMMERCIAL
URBAN INTERFACE AREA E]NO
FLOOD ZONE ElNO
EICHLER HOME?
DESCRIPTION OF WORK
TOTAL VALUATION: �� EKED a
2 00 �.. .r
By my signature below, I certify to eac Ing: I am the property o uthorized agent to ac on t e property owner's behalf. I have read this
application and the information ve provided is eo ect. I have read t escr' on of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relat g to b (ding co ction�,a o e representatives rtino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED - OFFICE USE OlYLYkc. ?N ,
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MEPMiscApp_201 1. doc revised 06/21/11
CITY OF CUPERTINO
FF.F. ESTIMATOR — BUILDING DIVISION
i0iADDRESS:
23500 CRISTO REY DR 110C
DATE: 04/22/2015
REVIEWED BY: MELISSA
UNITS
APN: 342 53 019
BP#:
-VALUATION: 1$1,200
PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Multi-FamilyDwelling
USE: g
Buildina is
>3 Stories 0 Yes (E) No
PENTAMATION 1REAP11
I PERMIT TYPE:
WORK
UNIT 110C - INSTALL 4 RECESSED LIGHTS IN LIVING RM
SCOPE
Suppl. Insp P'ee
APPLIANCE / EQUIP TYPE
FEE ID
A
� a
Elec. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Fixtures, Lighting
1BREMFIXT
Other Elea Insp. 0.0 hrs $48.00
4
#
$72
Permit hee:
Suppl. Insp P'ee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? ® Yes (E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$72 00
Strong Motion. Fee: 1BSEISMICR
'
11himb. Plan Cheel(
A
� a
Elec. Plan Check 0.0 1 hrs $0.00
Ifec h. Plan (.heck
L1, r,1, Permit Fee:
Plumb. Permit Fee:
Elec. Permit Fee: IEPERMIT
C3rher hlech. Insp.
Other Plumb Insp.
Other Elea Insp. 0.0 hrs $48.00
?Perla. Insp� Fee:
Plturnb. Inst. lee:
Elec- Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Hire, sanitary fewer Distri, school
71.1-1,.;,.. „r.. Th— foac nro hncod nn tho erolisninary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check 14'ee:
.S1'1f)l)1..P(.' Tee
PME Plan Check:
$0.00
Permit hee:
Suppl. Insp P'ee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? ® Yes (E) No
$0.00
Advanced ed Planning 14'£,?es:
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion. Fee: 1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission .Fee: IBCBSC
$1.00
NML,� a
: fi m ay
$214.50
3 Ta AL'
$0.00 Igoe _
$214.50
Revised: 04/01/2015