10080096 CITY OF CUPERTINO BUILDING PERMIT
ILDING ADDRESS: 21478 METEOR DR CONTRACTOR:SHRIKRISHNA BHANDARE PERMIT NO: 10080096
✓NER'S NAME: SHRIKRISHNA BHANDARE
21478 METEOR DR DATE ISSUED:08/16/2010
ER'S PHONE: 4086893900
CUPERTIN 3,CA 95014 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION gUILDIN<'PERMIT INFO: BLDG r ELECT PLUMB
ense Class Lic.# MECH F RESIDENTIAL F COMMERCIAL
ntractor Date
JOB DESCRIPTION:POOL REMOVAL
ereby affirm that I am licensed under the provisions of Chapter 9
mmencing with Section 7000)of Division 3 of the Business&Professions
de and that my license is in full force and effect.
ereby affirm under penalty of perjury one of the following two declarations:
ave and will maintain a certificate of consent to self-insure for Worker's
,mpensation,as provided for by Section 3700 of the Labor Code,for the
rformance of the work for which this permit is issued. Sq.Ft Flom•Area: Valuation:$5000
ave and will maintain Worker's Compensation Insurance,as provided for by
ction 3700 of the Labor Code,for the performance of the work for which this APN Numt er:32644002.00 Occupancy Type:
rmit is issued.
APPLICANT CERTIFICATION
ertify that I have read this application and state that the above information is
rrect.I agree to comply with all city and county ordinances and state laws relating PER WIT EXPIRES IF WORK IS NOT STARTED
building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
en the above mentioned property for inspection purposes. (We)agree to save
demnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
ists,and expenses which may accrue against said City in consequence of the /
anting of this permit. Additionally,the applicant understands and will comply
ith all non-point source regulations per the Cupertino Municipal Code,Section Issued by; Date:
18.
ignature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs sl call be inspected prior to any roofing material being installed.If a roof is
installed w thout first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
he following two reasons:
as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
rill do the work,and the structure is not intended or offered for sale(Sec.7044,
lusiness&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
,as owner of the property,am exclusively contracting with licensed contractors to
onstruct the project(Sec.7044,Business&Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
hereby affirm under penalty of perjury one of the following three
I have res d the hazardous materials requirements under Chapter 6.95 of the
leclarations:
have and will maintain a Certificate of Consent to self-insure for Worker's California t Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
:ompensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
)erformance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
have and will maintain Worker's Compensation Insurance,as provided for by Additions By,should I use equipment or devices which emit hazardous air
lection 3700 of the Labor Code,for the performance of the work for whic s contamin ants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
)ermit is issued. Health&Saflty Code,Sections 25505,25533,and 25534.
[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 Own hor' a r
Compensation laws of California. If,after making this certificate of exemption,I Date: v�
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed r v CONSTRUCTION LENDING AGENCY
�r I hereby i ffirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
i-'-,nnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
g._.ling of this permit.Additionally,the applicant understands and will comply I underst and my plans shall be used as public records.
with all non- oint rce re gu ations per the Cupertino Municipal Code,Section
9.18. Licensec Professional
Signature Date
CITY OF CUPERT:ENO
3 ITEMS OF 3 PERMIT RECEI:?T OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32644002 . )0
DATE ISSUED. . . . . . . : 08/16/201)
RECEIPT #. . . . . . . . . : BS000011133
REFERENCE ID # . . . : 10080096
SITE ADDRESS . . . . . : 21478 METEOR DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SHRIKRISHVA BHANDARE
ADDRESS . . . . . . . . . . : 21478 METEOR DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SHIRKRISHVA BHANDAR
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : SHRIKRISHVA BHANDARE
ADDRESS . . . . . . . . . . : 21478 METEOR DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 000 . 00 1 .00 0. 00 1. 00 0 .00
1BSEISMICR VALUATION 5, 000. 00 0 .50 0 . 00 0.50 0. 00
1DEMOPRE EACH 1. 00 291. 00 0 .00 291. 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 292 .50 0. 00 292 . 50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 292 .50 AMEX
---------------
TOTAL RECEIPT 292 .50
VOICE ID DESCRIPTION VCICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
( - C/y
CITY OF CUPERTINO ll
DEMO
PEr
TCU �,1NO PERMIT APPLICA-RON FORM
APN# -- , � _
Date: og1t,j ju
Building Address: 0,1479 F1 to o r p i^ u e�' '►� c `ism) y
Mailing Address (if different from building address):
Owner's Name: Phone:
Shrr krVt iAV-Ci haV,cAc� re
Contractor: Phone
Fax:
Contractor License #:
Cupertino Business License#:
Phone:
Contact:
00V�V, Fax:
Residential [[�Sq Footage Commercial ❑ Sq Footage
Job Description:
�ICAM 0 v�i
Valuation:
Project Size: Express Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group- Permit Type
1DEMORES Demo-Resident.al B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DEM-
1BCBSC Cal Bldg Standards B ALL PERMIT
rCommission Fee TYPES
l
1BSEISMICRE Seismic Resi&-itial B
Revised 01/07/09
CITY OF CUPE RTINO
FEE ESTIMATOR-BUILDING DIVISICBiMOLITION
ADDRESS: DA7 E: REVIEWED BY:
lu'l APN: BP h `VALUATION: 1$5,000
*PERMIT TYPE: Demolition Permit
PRIMARY Swimming Pool, Res. APPLICATION
USE: g TYPE: 1 SFPOOLDEM
WORK
SCOPE
FEE ID #POOLS
1 DEMOPRES 'I
77777.7,
„ .. ,. a t
���'T ,r'S �'"'
PhImb. 17(11?C�hr ch 7r c'. l'lr�r;f-'h�rek
1 Ji,
„j,. P,:J 1)ti!
Prnrr!'�!r /' C)"ho.f,,`:'r. In,V).
1'I'r!uti:� lrtry'. /•";' /;(iv lrrs/� /'r't.
NOTE: Thesefees are based on the preliminary information available and are onl an estimate. Contact the De t or addn'[info.
FEE ITEMS fFee Resolution OI-051 Elf 71/1J FEE QTY/FEE MISC ITEMS
Strpt�•'
Phw,- `.Ic, h.;E/cc Plan Check:
Permit Fee: $291.00
Suppl. Insp. Fee{'0 Reg. O OT 0.0 hrs $0.00 .
Plrnrri: IzI;lc'c: C'rrit I'c :
Ph I, 1!!c/r, 17c'c l Pcrmil Fc'c.
r!1t>rl rr; !ion 1'eL1
Ii'rr}•r:. tt;,%�uu!1'(frl7ril',
Yi crt_ %' rnra r:1;:rlicrn F("s
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldp,Stds Commission Fee: IBCBSC $1.00
i,
sUsrbTALS': $292.501 $0.00 �t TOTAY,FEE� $292.50
.,u
Revised: 8/12/2010
PROJECT
v S rr
Enter description here,and enter points available for measure in appropriate categories to the right � y - y 0 0 0. 0 0 0
_JjElder descriptor here,and anter points available for measure In appropriate categories to the right 0- 0 0.4 D 0 0'
Enter description here,and enter points evateoie for measure in appropriate categories to the riphL 0
~ Enter description`hare,and enter points avallable for measure in appropriate categories to the right . _ 0.. �D —D 0+ 0 -a
Build It Green Checklists and
4.Innovation:List innovative measures that meet the green building objectives of the Guidelines.Enter up to a
maximum combined total of 20 pts.See Innovation Checklist for suggested measures,u:Ing the link to the right.
Inry alion In Community.Enter description hem,and enter points available for mass=in appropriate categories to the rir it. 0 to D 0 0 0
Innovation In Energy:Enter description here,and enter points available far measure In appropriate categories to the right —0— 0�— D}r -0 D 0
Innovation in WYHealth:Enter description here,and enter points available for measure in appropriate categories to the rig hL 0 �D^ 0 y, D~ 1V.
D
Innovation In Resources:Enter description here,and enter points available for measure Inappropriate categories to the riF nl. rJ0 0_ 0 0 0 0
Innovation In Water:Enter description here,and enter points avallatde for measure In appropriate categories to.the right 0.__ 0 •. YO D 0 D
Total Available Points In
Other=4 0
Summary
Total Available Poi•tts in Specific Categories' 4+ 96+ 42+ 66+ 43+
Minimum Points Required in Specific Categories 0 30 5 6 9
rtal Points Achieved 1 1 1 1 1 1
Project has not yet met the following recommended minimum requirements:
Total Project Score of At Least 50 Points r
-Required measures:
-A3a: 50010 waste diversion by weight
-12: 15%above Title 24
-Nl:Incorporate GreenPoint Rated Checklist into blueprints
-Minimum points in specific categories:
i -Energy(30 points)
-lAQ/Health(5 points)
-Resources(6 points)
-Water(9 points)
0 2007 Build It Green Single Family GreenPDint Cheddist 2017 Version Page 7 of 7
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•B JILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014.3255
(408)777-3228• FAX(408)777-3333•buiidino�c�ca�er[in�.orc
CUPERTINO
Dear Property Owner(s): ourself as the builder of the property
An application for a building permit has been submitted in your namf,listing y
improvements specified at:
i`le
BP#
p ���r�h0 PN
� a
SITEADDRESSA'",Ig Met-er,r, r
O NER NAME OWNER ADDRESS
c1AY` C erg c,A
, " tiCkh Ckre_ 2
DESCRIPTION OF WORK: Oce
We are providing you with an Owner-Builder Acknowledgment and
I frmation Verification
your n Form to make you as the Owner-aware
ero We
your responsibilities and possible risk you may incur by having thispermit
will not issue a building permit until you have read,
initialed An went of the ownergannot executelth snnofige un less and
returned this form to us at our official address indicated
you,the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
( CTIONS:Please read and initial each statement below to sicmify you understand or verify this information.)
ain an"Owner-
e I understand a frequent proud ou lthattheersons is to property ownereishe property owner provid ng his or her otwn labor and material
Builderi'building permit that erroneouslyimpliesinjuries sustained
personally. I, as an Owner-Builder, may be held liable and sut ject to serious financial ihomeof or any
insurance may not y
an unlicensed person and his or her employees while working on my property. Y
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
surance coverage for injuries to workers on my property.
I.U?"_�_eoons
2. 1 understand building permits are not required to be si(ined by property owners unless they are responsible for
truction and are not hiring a licensed Contractor to aE sume this responsibility.
nders
that I
d on the permit. I u
3. I understand as an"Owner-Builder" I hiring a Iicenseche ble party of Cntractorrandrhavng the permit filed inchsdor hermay
ct myself from potential financial risk by
jumbainstead of my own.4.1 understand Contractors are required by law.to be lic:nsed and bonded in California and to list their license
me
ers on permits and contracts.
4 5. l understand if I employ or otherwise engage any per:;ons,other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ;$500),including labor and materials, I may be
0nsidered an"employer"under state and federal law.
I must
ister with the state
6. 1 understand if I am considered an"empl workers' compensation r 3tate federdisabial �lity insurance,and contribute t and
federal government,withhold payroll taxes, provide
unemployment compensation for each"employee." I also unJerstand my failure to abide by these laws may subject
me to serious financial risk.
lder
7. I understand under California Contractors'
with theeinter�t to offer, an themOfor sale,iunlesshalbwodrk is performed by
esidential structures cannot legally build
licensed subcontractors and the number of structures does iot exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
e held
8'I understand as an Owner-Builder ifb salnthe
subsequr nt ownewhich
r(s)thatresulltls issued, I may from any latent bonstructionliable for
any financial or personal injuries sustained y Y
defects in the workmanship or materials. 4,nerBuilderForm_2010.doc revised 04/14/10
9. 1 understand I may obtain more information regarding ny obligations as an"employer"from the Internal
evenue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors'State
License Board(CSLB)at 1-800-321-CSLB (2752)or www.esli).ca.gov for more information about licensed
ontractors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that I
Information
he party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
applicable laws and requirements that govern Owner-Builders as well'as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license,the C ontractors'State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint:Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property,;you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their corkers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Addre:s:
Before a building permit can be issued,this form must be completed and signed b theproperty
returned to the agency responsible for Issuing the permit. Notepy of th:A co g y 'owners dridri owner and
e property driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the propeq owner's si nature.
Property Owner's Signature: Date:
-- - -- - - ---------------------------------------------------------------------- --- -- - ---- ---- - -- --- --- - - ---
(NOTE: The following Authorization Form is required to be complet sd by the property owner only when designating an
agent of the property owner to apply for a construction permit for thE- Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to aPC ly for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work): U 1 Ke))vm'V'C111
Project Location or Address: �, �-p TR NW-_- LzjR �? C u p ue_ cf-i- �
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for thE.address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the grope ty owner's driver's license, form notarization, or other
verification acceptable to the city maybe r quired to be presented woen the permit is issued to verify the property owner's
signature.
Property Owner's Signature` — Date x:13 b i0
Tr
OwnerBuilderForm 2010.doc revised 04114/10