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15050086CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR CONTRACTOR: CITY BUILDING PERMIT NO: 15050086 INCORPORATED OWNER'S NAME: THE FORUM RANCHO SAN ANTONIO 212 N SAN MATEO DR DATE ISSUED: 05/14/2015 OWNER'S PHONE: 6509440100 SAN MATEO, CA 94401 PHONE NO: (415) 495-6000 LICENSED CONTRACTOR'S DECLARATION I(IL JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ MAIN BUILDING - IN ROOMS # 63 & 65; REPLACE License Class C r' . t Lie. #-� COUNTER TOPS, SINKS & SHOWER PANS IN BOTH Contractor Date W BATHROOMS, REPLACE (E) OUTLETS/SWITCHES (26 TOTAL) 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 erformance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $10000 hi 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: _ ' q , t) Occupancy Type: permit is issued. o- + 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 WITIIIN 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 DAY D 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 jib Y �/ granting of this permit. Tonally, the applicant understands and will comply ss ate: with all non-point soVgUtionsper the Cupertino Municipal Code, Section 9 18.^'-oRE-ROOFS: Signature Date 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 (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 Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505 25533 and 25534. Section 3700 of the Labor Code, for the performance of the work for which thisw Owner or authorized agent: — Date�;-�:'� V 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 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 E ! O CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENTDEPARTMENT • BUILDING DIVISION / 10300 TORRE AVENUE • C.UPE.RTINO, CA 95014-3255 1�O (408} 777-3228 • FAX {408} 777-3333, •i ildncupeFtino.£>rcI . J L�P�I2'6'6a Q'N#st3,•'C:ONSTRL C: i10Nti i F ADDITION E ALTERATION iTI _ f RI'VISION /;DE ERTtEsIY (1I21GINAfL 1,E—....' - PROJF(1'AT DR! -;SS 23500Cristo:Rey Drive. Room #0 & #65 OWNERNAN'r The Forum at Rancho San Antonia ! PILotiE: 100 Hernandez@thef'oru,mrsa.com.. Ci50.944"OT00 STRIEET.A,DVRES5 .. CIT CSinLEP- .� PAX CITY, STATE, 23500 Cristo Rey Drive, C a,9SU14 Pli(D`�.Ri ... k^..t FOPTa YL: AlloWes 415.8150.2021 Pf hwest�c tytDu lding.com'I' A[)I.DR%55 - CITY 'TATE, NP FAX I _, -❑ V.OPER❑'ENANIr . M ' I bESC RIPI'aON'OF WORK: .k as so L erto at.t�vn hit rot�nxs Ttel� �r ciiow� r p Isz3rf aI_ cT+�+ StliTri �n 3 Replace r i___ting�li�ns i1witches with new: TR DeCora. Two Guest Rooms #63 and #55 i [XISiIhG.LSI?. f ROPOfiI?1)t SG t'cDPaS'rR..TD'PE; ,: C ONTRACrOR NAME I ICF:N$I3;�7i M1ff#F;i£ 32i.3 s. L ICL NSI4'L'S Pr> B,C20,C35 BIS. LIC N 35043 Patrick PellcDc4 s VALUATION (S} COMPANY NAME ,�•S1A11.. I)fellolAes( citybuild nl;.£tam EAI. Cily Bu ld ri Inc STI21:ET ADDRESS CITY, STATE ZIP San Mateo Ca 94401. PHONE, i 'i" 4 i 3 2? 2 NSan Mateo Drive ARCHITEX7,:NIGINEERNAMI 1IC`I:NSI_ukiM8F'R A i ............. BUS ,.LIC 9 COMPANY NAME... .. .. P:•NSAIL, FAX STREETAt DRESS Y ..CITY, STATE, ZIP, PHONE, .......:.._ 11 RCftiRFA DICK :AREA OT AL 1),C F-TO.P IIARE GAKAGE.A_A DE ACC bESC RIPI'aON'OF WORK: .k as so L erto at.t�vn hit rot�nxs Ttel� �r ciiow� r p Isz3rf aI_ cT+�+ StliTri �n 3 Replace r i___ting�li�ns i1witches with new: TR DeCora. Two Guest Rooms #63 and #55 i [XISiIhG.LSI?. f ROPOfiI?1)t SG t'cDPaS'rR..TD'PE; 4.5'i'EDtti}FS L sF. TYNE:' occ. VALUATION (S} EXISTC EW 1 t 00°[,� DIrNS4 ARI 1. A .LiA TOI l 'flb"7 A13'bABATHROOM , AREA v-Ao S ;'J L rrt ... MO . (D[)fiI'_AREA, RE'Mi)DE?L. .iREr� REM1iODLI, ARL' 4 RIA1 01, 1 .._.._._.._... .. .......:.._ 11 RCftiRFA DICK :AREA OT AL 1),C F-TO.P IIARE GAKAGE.A_A DE ACC ...._. I - _.. >t•t)u T;LI.41JC t;NiTS' 149SECYSht)t\IZ [�Y'ES SCCCD'VD SS'QR1' DRCS`.... Rr,I N£ ADDED Lti ADDITION? -PI'LIC':A11O1 D YES II YkPROVIDE ROVIDE COPY OF R}tr rt IS Tt1f 61 Df.. AN ❑ YLS IVED 7Q7:A.L YA1.L iTLt�N: NL:'#'v LtiNO-AiPL= []NOPQ.NNINTO APPROVAI, IXTUA EI£iiiF,LR no I.'- �*. CITY OF CUPERTINO ...... FVF, ESTIMATOR - BUILDING DIVISION [Xfech. Plan Check Plumb. Plan Check 0.0 hrs $0.06 Elec. Plan Check 0.0 hrs $0.00 hlech. Permit Fee: Other Alech. 7nsh. Yech. Insp. Fee: Plumb. Permit Fee: IPPERMIT Elec. Permit Fee: ]EPERMIT Other Plumb Insp. 0.0 hrs $48.00 Other Elec. Insp. 1 0.0 1 hrs 1 $48.00 PIwO. Insp. Fee: 1 lec. InsE2. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, lire, sanitary Fewer District, scnoot n:..s...Tl...o.. nn n n t.nnnii nas /Gn nvn/issfin n.nr in in>rsssnlinN nvminhJO nH/t /lr0 AHIV nN OC/IN1af0_ rantart tho Mmt for addn'l info. FEE ITEMS (Fee Resolution 11-053 E f 7/1113) ADDRESS: 23500 CRISTO REY DR DATE: 05/14/2015 REVIEWED BY: MELISSA APN: 342 53 100 BP#: *VALUATION: 1$10,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY Multi -Family Dwelling USE: Building is 1 >3 Stories 0 Yes 6) No PENTAMATION 1 RPFIX PERMIT TYPE: WORK MAIN BUILDING - IN ROOM # 63 & 65; REPLACE COUNTER TOPS SINKS & SHOWER PANS IN SCOPE BOTH BATHROOMS, REPLACE (E) OUTLETS/SWITCHES (26 TOTAL) [Xfech. Plan Check Plumb. Plan Check 0.0 hrs $0.06 Elec. Plan Check 0.0 hrs $0.00 hlech. Permit Fee: Other Alech. 7nsh. Yech. Insp. Fee: Plumb. Permit Fee: IPPERMIT Elec. Permit Fee: ]EPERMIT Other Plumb Insp. 0.0 hrs $48.00 Other Elec. Insp. 1 0.0 1 hrs 1 $48.00 PIwO. Insp. Fee: 1 lec. InsE2. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, lire, sanitary Fewer District, scnoot n:..s...Tl...o.. nn n n t.nnnii nas /Gn nvn/issfin n.nr in in>rsssnlinN nvminhJO nH/t /lr0 AHIV nN OC/IN1af0_ rantart tho Mmt for addn'l info. FEE ITEMS (Fee Resolution 11-053 E f 7/1113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 ® # $40.00 Plumbing IBPFLYTURE I Fixture set on One Trap Suppl. PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 26 $78.00 Electrical 1BREMRECEP Recep/Switch/Outlets Permit Fee: $0.00 Suppl. Insp. Feer Reg. Cl OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $96.00 Construction Tax: Administrative Fee: ]ADMIN $45.00 0 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure i Travel Documentation Fee: ITRAVD0C $48.00 Strong Motion Fee: 1BSEISMICR $1.30 Select an Administrative Item BldgStds Commission Fee: 1BCBSC $1.00 ; _SITBTC1TALsc _ $191.30 $118.00 - TOTAL FEE: ° , $309.30 Revised: 05/07/2015 at Rancho San Antonio. Rooms 63 and 65 Cristo Rey Drive Room 63 & Room 65 ALL CA 2013 BLDG CODES APPLY Ly sink and countertop at two bathrooms. Replace shower pan and shower surround at Replace existing plugs and switches with new TR Decora.