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10090256I CITY OF CUPERTIvO BUILDING PERMIT I BUILDING ADDRESS: 22431 PALM AVE I CONTRACTOR: FOLEY ELECTRIC INC I PERMIT NO: 10090256 I OWNER'S NAME: NYLES NETTLETON 919 ARGUELLO ST ER'S PHONE: 4088071249 REDWOOD CITY, CA 94063 DATE ISSUED: 09/28/2010 PHONE NO: (650)369-2878 LICENSED CONTRACTOR'S DECLARATION I BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB r License Class IN C /0 Lic. # c3.w 6 I MECH r r RESIDENTIAL COMMERCIAL contractor 6 /k/ X 1ee_7WG Tr✓G Date `7 Z ^ ld [ herebyaffirm that I am licensed under the rovisions of Cha ter 9 JOB DESCRIPTION: ADD 125 AMP SUB -PANEL INSIDE GARAGE (commencing with Section 7000) of Division 3 of the Business & Professions **SEE NOTES** 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. /*0 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 9.18. Signature Date "l0 '1000, OF D OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one o' 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 mug t 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 relatin; to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save i• nify and keep harmless the City of Cupertino against liabilities, judgments, C 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 9.18. Sq. Ft Floor Area: I Valuation: $1100 APN Number: 35703076.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued bDate: L^, i 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 Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorize agent: Date: 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. I Licensed Professional Signature Date �� CITY OF CUPERTINO IAI FEE ESTIMATOR - BUILDING DIVISION ij,ADDRESS: FEE ID QTY/FEE DATE: REVIEWED BY: BP FEES APN: BP#: *VALUATION: 1$1,100 *PERMIT TYPE: Electrical Permit 100 PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex I r 1I , II. PENTAMATION 1 REAP2 USE: t �)t�f; ;;�� PERMIT TYPE: 14 WORK $42.00 PME Permit Fee: $42.00 C�.�,Irs'tl rlc /r)r Tax SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Services 1 ERT<200 Other Elec. Insp. hrs $42.00 0.0 100 Amps $42 IYI-Init 1`c c: sl!/)/)/. Ins/) PME Unit Fee: $42.00 PME Permit Fee: $42.00 C�.�,Irs'tl rlc /r)r Tax /1;UCfS(Ft 'C trr 1\L-`i'Ie'21; t'C'E': Work Without Permit? 0 Yes No 60.00 TOTALS: Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: Mt)TF. Th- Fooc nro hnaod nn rho nrotiminary infarmatiat available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS )Fee Resolution 09-051 Eff. 7%1;10) FEE QTY/FEE Elec. Plan Check 0.0 1 hrs $0.00 P/an C'hcck ['e .- F w i cc- � t ... Elec. Permit Fee: IEPERMIT 0i,c, I .t��;� t)r',; � „�, ty�;,, ELI Other Elec. Insp. hrs $42.00 0.0 PME Plan Check: 30.00 Mt)TF. Th- Fooc nro hnaod nn rho nrotiminary infarmatiat available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS )Fee Resolution 09-051 Eff. 7%1;10) FEE QTY/FEE MISC ITEMS P/an C'hcck ['e .- lipjzl, PC /",>e PME Plan Check: 30.00 IYI-Init 1`c c: sl!/)/)/. Ins/) PME Unit Fee: $42.00 PME Permit Fee: $42.00 C�.�,Irs'tl rlc /r)r Tax /1;UCfS(Ft 'C trr 1\L-`i'Ie'21; t'C'E': Work Without Permit? 0 Yes No 60.00 Travel Documentation Fee: ITRA VDOC $12.00 Strong Motion Fee: $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.50 $0.00 TOTAL FEE: $127.50 Revised: 9/22/2010 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Bl<: Lot: APN ........: 35703076.00 DATE ISSUED.......: 09/28/2010 RECEIPT #.........: BS000011578 REFERENCE ID # ...: 10090256 SITE ADDRESS 22431 PALM AVE SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER ............: NYLES NETTLETON ADDRESS ..........: 22431 PALM AVE CITY/STATE/ZIP CUPERTINO, CA 95014 OPERATOR: patg COPY # : 1 RECEIVED FROM FCLEY ELECTRIC INC CONTRACTOR SCOTT ZELTMANN LIC # 23196 COMPANY FC,LEY ELECTRIC INC ADDRESS 939 ARGUELLO ST CITY/STATE/ZIP ...: REDWOOD CITY, CA 94063 TELEPHONE ........: ((50)369-2878 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 1,100.00 ---------- 1.00 ------ 0.00 1.00 0.00 1BSEISMICR VALUATION 1,100.00 0.50 0.00 0.50 0.00 1BUSLIC FLAT RATE 1.00 114.00 0.00 114.00 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1ERT<200 UNITS 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 ---------- 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 241.50 0.00 241.50 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 241.50 --------------- 241.50 VOICE ID DESCRIPTION -------- ---------------------------- 103 UFER 505 FINAL ELECTRICAL REFERENCE NUMBER -------------------- #5112 VOICE ID DESCRIPTION -------- ---------------------------- 304 ROUGH ELECTRICAL Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS• y3 / PERMIT # OWNER'S NAME: /V /� T PHONE # GENERAL CONTRACTOR: F IF F 1' c BUSINESS LICENSE # ADDRESS: i/ q+2 CITY/ZIPCODE: �YOG3 *Our municipal code re fires all businesses working it the ci to have a City of Cupertino business license. EDULED UNTIL THE NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) HAVE OBTAINED AHCITY OF CUPERTINO GENERAL CONTRACTOR AND ALL SUBCONTF:ACTORS BUSINESS LICENSE.F P ,f 9.2 g ._1p I am not using any subcontractors: Signature Please check applicable subcontractors and comp ete the following information: V SUBCONTRACTOR I BUSIM Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date 7 -�'-/o F Date Owner /Contractor Signature CITY OF CupEKINO %00(� OZ CITY OF C ITPERTINO GENERAL BUILDING PERNHT APPLICATION FORM �N # � k-,LOQ3 00'1 (p Building Address: in PAIm AVX Mailing Address (if different from building address): Are Hazardous Materials being used as part of thi: project? Yes U No L& HOA: (Exteriorworkonly) Yes ❑ No If es, rovide letter from HOA Owner's Name: Phone #: yag- Al iE IVC- W Contract : Phone: sa _ r >_ . Air J,_ --7e r,. -7-^//7 Fax: Date: ?-as -a8 Contractor License #: 3,z/,50 to Cupertino Business License #: Contact: �� f �� Phone: Sb - 3!0 C/ - 2 9 7g , ;,, Fax: Residential Commercial Job Description: / ,A U/a%r�� A /dsaM,o S t� P.sn/6L TN 5; E �'veA q Building Permit Info: Bld ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: C2� 1-B ❑ II/ITI/v-A ❑ II/VI B, IV -HT, V Valuation: Square Footage: /OD Lar e Major ❑ OT Project Size: Express DSS g Green Building: Please complete relevant portioli of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. 'oints Achieved: $ For help, contact Build it Green at www.builditQreen.or Revised 07/14/09