14100115 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 412G CONTRACTOR:BAY AREA PERMIT NO: 141001 15
ENTERPRISE
OWNER'S NAME: ROSE THEIMER 2110 MANGIN WAY DATE ►SSUF.D: 10/23/2014
OWNER'S PHONE: 6503214558 SAN JOSE,CA 95148 PHONE NO:(408)238-5043
❑ LICENSED CONTRACTOR'S DECLARATION
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ley ty
BUILDING PERMIT INFO: Bloc ELECT PLUMB
License Class Lic.4
MEC11 RESIDENTIAL COMMERCIAL
Contractor Fitw pate [C U�� JOB DESCRIPTION: INTERIOR REMODELI.(549 SQ FT)INCLUDING CRFA'IING
/ J AN OPENING TO UNIT 414'i
1 hereby affirm that 1 am licensed the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
C de and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to sell'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. Sq.Ft Floor Arca: Valuation:$20000
1 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
ANN Number:34253194.00 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 180PAYS FR AST 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 t'
granting ofthis permit. Additionally,the applicant understands and will comply Issued b/ Date:
with all non-point sour regulation per the Cupertino Municipal Code,Section
9.18.
1RE-ROOFS:
(�
Signaturc Dale l All roofs shall be inspected prior to any roofing material being installed. Iha roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Datc:
1 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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California health&Safety Code,Sections 25505,25533,and 25534. 1 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: Ilcalth&Safety Code,Section 25532(a)should I sto" or handle hazardous
I have and will maintain a Certificate ofConsent to self-insure for Worker's material. Additionally,should I use equipment or vices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the B y A �a Air ality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the C per no M cipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections 25533, nd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this g ld/2-t �(l
Owner or authorised agent: Date: /1 t7
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 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 ol'
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this pernil is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's
I certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and slate 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, ARCHITECT'S DECLARATION
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 Dale
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 23500 Cristo Rey Dr(unit 412G) DATE: 10/21/2014 REVIEWED BY: Sean
APN: BP#: J r ��S� 'VALUATION: 1$20,000
°PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY Multi-Family Dwelling Buildino is PENTAMATION 1R2REM
USE: 3 Stories Q Yes ® No PERMIT TYPE:
wORK Interior remodel 549 sq ft including creating an opening to Unit 414G.
SCOPE
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El
11;"r°yr /m,;. ict. /'lia?lli',. 1,,;.,. r` . �f.°...fi�.t:. �<•
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelinddna information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E 7/1.-Q FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F-9497 s.f. Remodel,Other
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $503.00 IREMRESOTx
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-0 Reg. Q OT 0 0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Work Without Permit? 0 Yes 0 No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential Q
Building or Structure 0
Strong Motion Fee: IBSEISMICR $2.60 Select an Administrative Item
Bldg, Stds Commission Fee: IBCBSC $1.00
SUBTOTALIS�. $3.60 $503.00 TOTAL FEE: $506.60
Revised: 08/20/2014