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05030133 CITY OF CUPERTINO ..,�,: ;, sro.+� ';;a BUILDING DIVISION PERMIT ' CONTRACTOR INFORMATIQN BUILDINGADDRESS: MDR NELSON RAMOS PERMRNOOSO30133 OWNER'S NAME: PERMIT ISSUE DATE ONE: SANITARY NIT. CONTROL N0. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 coo LICENSED CONTRACTOR'S DECLARATION C I Mushy affirm Nat 1 am licensed under provisions of Chapter 9(commencing Job Description od U with Section 7")of Division3 ofthe Business and Professions Code,and my license is 5 nmmnromeand erre"' = License force eLk.N REPLACE BATHTUB/PLUMB/VALVE/TILE z rtj Dam T' r BATHTUB, VALVE AND WALL/FLOOR TILE ZZ'-{' ARCHITECT'S Comment, DECLARATION �i toI undersand my plan shall W used a public meet& Dir aans U 3 oto Licensed Prorcssional i OWNER-BUILDER DECLARATION <f I hereby affirm Nal 1 am exempt from the Contractor's License Law for the -00 fallowing reeon.(Section M1.5.Business and Professium Cosec:Any city or county K$� which requires a Permit to construct,eller,improve,demolish,or aped,my svucam prior in its issuance.also requires the applicant for such permit to file a signed statement that he is licensed pursuant o the provisions of to Contractor's Liaise Law(Chapter 9 Sq.Ft. Floor Area Valuat 00 �reFa (commencing wit Section 7000)of Division 3 or the Business and Professions Code)or - that he is exempt themfmm and the basis for the allepil exemption.Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant m a civil Penalty of APN Number Occupancy Type not mom them five hundred dollen($500). ❑1,as owner of the ppony,or my employees with wages as their sole compensation, 32617036 . 00 will do Ne work and the swcture is not intended or offered for sale(Sec.7004,Business and Proressions Cade:The Contmeter's License law does not apply m an owner of Required-Inspections property own enywho s.parcds mimprow Orcmon.and who nocsauchended Unfitted! through his own employees.provided mm such impmvemw t am not tended mplatired forsidtthe ow.r. 4 however,me building or improvement is sold within one year ofimp olve f r me owner. Guilder will have me burden of proving mu he did not build or improve for purpose of ,\ ❑1. u awmcf of the Property,,B sines and contractingofesswise licensed rontramom m come La the es not (Sec.a an Business and property who Cade:)TheContraction'sthe on. d come law dam not chplro be an owner of proper&who Wilds or improve Norton,and whence Lacu for such projects with a conuactar(i)licensed Pursuant to Ne Conuactofs License Law. ❑l am exempt/untiv Sec. .B&P C Tr MU r7a Owner �0 Of 0 ER'S COMPENSATION DECLARATION - 1 hereby affirm under penalty of pc jury one of the following declvatiom: 1 have and will maintain a Cerdfieam of Consent in self-intim for Worker's Compere ian,as provided for by Section 3700 of the labor Coda,for the performance of Or 1r37W rk for which this permit is issued. 1 have and will maintain Wester's Compensation Insurance,as required by Section of the labor Code,for the performance ofNe work fm rmwhich this peit is issued. y Worker's Compensation Insurance carrier and Policy number am: Cartier: Policy No.: _ CERTIFICATE OF EXE IMON FROM WORKERS' COMPENSATION INSURANCE (This section need not W completed if the permit is foronc hundred dollars(Slip) or less.) 1 cerdW Nat in the performers f me wort for Rids Peemis u issued.I shall nm employ any Iversonin any manic ambo�p me�ubject mthe Werke C�m�fOsation Laws of California.Dam—� 6�KA Applicant NOTICE TO APPLICANT:If,after making its Certificate of Exemption,you should become tables,on tM Wainer's Compensation provisions of the Labor Code,you most �O ronhwith comply with such provisions or Nis Permit shall W accrued overrun. z^ CONSTRUCTION LENDING AGENCY F. 1 hcaby affirm on,there is a construction lending agency]or the performance of C the work(ser which this permit is issued(Sec.3097,Civ.C.) fy0 Underi Nene =z Lennert Address U O 1 minify Nat I have mad this application and ram that the above information is ly correct.I agree to comply with all city and county ordinances and state laws relating to �U building conswaian and hereby a oomim mpremnmtives of Nis city to enter upon the almvcmentioned Property for impaction Purposes. y (Wc)agree on save,indemnify and keep harmless the City of Cupertino against rn liabilities,judgments,cosy and expenses which may in my my accme against said City U in consequence of the granting of this Permit. ^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGU A ONS. I/ ej Re-roofs Signuure ofA mUConuactor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building Occupant store or handle hazardous material e defined by the Cupenino Municipal Code.Chapter 9.12,and lie Health and Safety Cw1c,Section 355J2(a)? Ye ❑Nu All roofs shall be inspected prior to any roofing material being installed. ❑ Will the applicant or future building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air contaminants as dcfned by to Bay Arca Air Qaalhy Management all new materials for inspection. District? C]yes C]No I have mad Or baaallous materials¢quiremcnts under Chapter 6.95 of the Calirm- ria Health&Safety Code,Santoro 25505.35533 and 25534.1 unticrsmnd Oat if the Wilding S does not currently have a tenant Nat it is my rcaponsihility,to nndly the oeeuPan,of the myvimmcnu wlNchytus,Wmc7tpVot �ancc ofa Ccrtificateo c0upmtDy. Signature oTApplicant Date YY3 // All roof coverings to be Class"B" or better owner err sumo sed agent Dam F Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPE(�TINO Building Department JOB ADDRESS: J0oCQEPERMIT #0�6 3 0) ,33 76 SCE�r7 mCUP�wo 25oi� OWNER'S NAME: WM PHONE # Z-Zt3 GENERAL CONTRACTOR: R J RAMD-s FAX # I am not using any subcontractors: 62, t Aso 3 I C> �S Signature Date Please check applicable subcontractors and complete the following information: 21 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting • Linoleum/ Wood Glass / Glazing Heating Insulation VILandscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering �/ Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile l Jao 3/roblr Owner/Contractor Signature Date Q- CITY OF CUPERTINO ITY OF PERMIT APPLICATION FORM CUPEINO APN# „ , Date: Building Address: Mailing Address (if different from building address): to - C-VF 2TiiQCf} ,5- Owner's Name: Phone #: K�-:o eco 4u t; 2- 2.83 Contractor: License#: MD2 L�srxl rt�„�s Contact: Phone: Cupertino Business License#: t6o woo Fax: Building Permit Info: FA,10. .0 , PIL--ka WOje , vol� , n..d --U-/ -Na*- E e Bldg LU Elect ❑ Plumb N Mech ❑ Job Description: Residential Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: $ 6 �b Occupancy Group: Type of Construction Please check this box if the project is a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to IM Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax -Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy - BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING Z � 1 of 3 L �• l/ CITY OF CUPERTINO CIT OF PERMIT APPLICATION FORM CUPEI,TINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP •Plan Check Repeat Fee BUILDING BPRE PIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backllo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 ICITY CITY OF CUPERTINO CU �TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance --- ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3of3