15100148I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 20200 LYNTON CT CONTRACTOR: R & L CONSTRUCTION PERMIT NO: 15100148
MANAGEMENT
OWNER'S NAME: GHARPURE SHRIRAM B AND JOSHI TEJASW 4036 TWYLA LN DATE ISSUED: 10/19/2015
OWNER'S PHONE: 4085681264 CAMPBELL, CA 95008 PHONE NO: (408)866-6643
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL TEMPORARY POWER POLE
License Class Lic. # I �j j a
Contractor C o(l.Sw cyCw `'v) Date
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.
Sq. Ft Floor Area: Valuation: $200
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
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 _ 1&,'uQ Date b 6 q�S
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
2. 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.
2. 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.
3. 1 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
APN Number: 36935021.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS ST CALLED INSPECTION.
Date: o
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, r autho •'z a en :
�i'Date: VW(q/1_5
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
must forthwith comply with such provisions or this permit shall be deemed I Lender's Address
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 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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
GENERAL PERMIT APPLICAT[ON MEP
COMNUNI TY DEVELOPMi�ENT DEPARTMENT • BUILDING DIVISION
10300 TORP.E AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildina(a-)cuoertino.org 15-1001 L// C'- m 1 V5 G
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IDESCRIPTION OF WOKK C ` ir- r �b w 1
aTOTAL VALUATION: 4 �r
By my signature below; I cerci y to each of the following: I am the property owner or authorized _-ent to act on e pr caner' ehal have read this
application and the information I have provided is correct. I have read the Description of'Work amd verify it is accurate. I agree com Nvith all applicable loc;q
al
ordinances and state laws relating to building
-construction. I authorize representatives of Cupertino to enter the above-ident1fi- eT ty for inspection purposes.
Si gna are of Applicant/Agent: - Date:
SUPPLEMENTA-L D�IFORv1ATION REQUIRED
M"EPA1'iscApp_2011. do revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20200 LYNTON CT DATE: 10/19/2015 REVIEWED BY: MELISSA
APN: 369 35 021 BP#: `VALUATION: 1$200
•PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 REAP1 A
WORK INSTALL TEMPORARY POWER POLE
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
P'ron"b'. h agf
QTY
UNITS
BP FEES
Elec. Permit Fee: ]EPERMIT
Temporary Power
1 ERT<200
Other Elec. Insp. 0.0 hrs $48.00
100
Amps
$48
aS`ul)[)I. Insj) F'ee
F-7
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
("ons,tiuction 'l. Cxx:
Administrative Fee: IADMIN
$45.00
Work Without Permit? Yes No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments (i.e. manning, runic worKs, Plre, January Jewer vistrict, acnuu[
Tfi�Erinf nin 1 %'lsnnn finno nrn Ancnri nzf lion nralh";sinry i»fnrmiy6n" inwHnhlo imd tyro nnhl tm octimnto rnntn!'t the DPW fnr addn'I infn_
FEE ITEMS (Fee Resolution 11-053 E . 7f /1/13)
tech. Plan Che ek
P'ron"b'. h agf
Elec. Plan Check 0.0 1 hrs $0.00
Meek 1'r's mil�_�:
1'r't�r�t1�. =ra�.r F-
Elec. Permit Fee: ]EPERMIT
Other.AA,ch..Insp.
Other Plumb lusp,
Other Elec. Insp. 0.0 hrs $48.00
;llech. Insp. 1[,`ee:
Plumb. Insp. 1`"ee:
11ec. Insp. }°eJc?
NOTE: This estimate does not include fees due to other Departments (i.e. manning, runic worKs, Plre, January Jewer vistrict, acnuu[
Tfi�Erinf nin 1 %'lsnnn finno nrn Ancnri nzf lion nralh";sinry i»fnrmiy6n" inwHnhlo imd tyro nnhl tm octimnto rnntn!'t the DPW fnr addn'I infn_
FEE ITEMS (Fee Resolution 11-053 E . 7f /1/13)
FEE
QTY/FEE
MISC ITEMS
Platz Check.Fee:
Sup/)/. P('-.' b'ee
PME Plan Check:
$0.00
aS`ul)[)I. Insj) F'ee
F-7
PME Unit Fee:
$48.00
PME Permit Fee:
$48.00
("ons,tiuction 'l. Cxx:
Administrative Fee: IADMIN
$45.00
Work Without Permit? Yes No
$0.00
,4dvcxnc°er./ .111(intztng .h'ee,s:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldp, Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$190.50
$0.00 TOTAL FEE:
$190.50
Revised: 10/01/2015