15050077 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10106 LAMPLIGHTER SQ CONTRACTOR:MAINE ELECTRIC INC PERMIT NO: 15050077
OWNER'S NAME: ANGIRA GOSWAMI 599 LEISURE ST DATE ISSUED:05/13/2015
OWNER'S PHONE: 4088889500 LIVERMORE,CA 94551 PHONE NO:(925)443-3377
r LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL F1 COMMERCIAL El
REPLACE(E)125 AMP PANEL,SAME LOCATION
License Class Li..4 S'
Contractor lkub Date 5-(3_P1jj
I hereby affirm that I am licensed under the provisions fi411mcapter 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:$2900
1 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 APN Number:34233001 00 Occupancy Type:
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 EXPIRES IF WORK IS NOT STARTED
permit is issued, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION 180 DAYS FROM LAST LED INSPECTION.
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 5��3LT
to building construction,and hereby authorize representatives of this city to enter Issu ate:
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 ROOFS:
all non-p ' t source regulatio s per the Cupertino Municipal Code,Section 9 18. All roofs shall be inspected prior to anyy roofing material being installed.If a roof is
. / installed without first obtaining an inspection,I agree to remove all new materials for
Signature Date
5�( t inspection.
Signature of Applicant: Date:
❑ OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
2. 1,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will
1 I have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the Health&Safety Code,Sections 25505,25533,and 25534.
performance of the work for which this permit is issued. n r r an 'ori e t i
2. I have and will maintain Worker's Compensation Insurance,as provided for by 9 %F, _r, Date: 3�3]�'"f
Section 3700 of the Labor Code,for the performance of the work for which this
Lvp—
permit is issued. CONSTRUCTION LENDING AGENCY
3. I certify that in the performance of the work for which this permit is issued,I shall
I hereby affirm that there is a construction lending agency for the performance of work's
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 for which this permit is issued(See.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name
must forthwith comply with such provisions or this permit shall be deemed Lender's Address
revoked.
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my plans shall be used as public records.
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 Licensed Professional
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
GENERAL PERMIT APPLICATION �� MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
90300 TORRE AVENUE•CUPERTINO,CA 950143255 D
CUPERTINO (408)777-3228•FAX(408)777-3333•building2cupertino.org �f MISC
[]PLUMBING
LUMBING —1
MECHANCAL.. ELECTRICAL MISCELLANEOUS
PROECP ADDRESS 10I() (0 �OLI b L TiI s0. APN# ' 7- 7
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OWNERNAME-- --"---- •- PH^'m — EMAIL
STREET'ADDRESS CITY,STA ZIP
1010 U [I��c.fes Sf� �KJ
CONTACT NAME /fh-&� V'i`i'� -E e,,7 PHONE qZ5 3 a G� L(2 d 3 E-MAIL
- ....__..
STREET ADDRESS r CITY,STATE,ZIP FAX
OWNER ❑ owNER Bu"ER ❑owmaAwfr ❑ CONTRACIDR ❑coNTRAmRAwa ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME aln �-2c�`�rc c., LICENSE NUMBER O'7 •7 i y LICENSE TYPE `' Q BUS.LTC#
-
COMPANY NAME E-MAIL FAX
sT 7 �,�'L,zisur-Z S' f' L�ua 0/` 2 ��SS ( S�2s yq3-3377
ARCHifECTIFNGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE,ZIP PHONE
USE OF q5ffMoiDUPLEX ❑ MULTI•FAMrY PROJECIINWB.DLAND ❑ YFS PROEECTIN ❑YES ISTHE BLDG AN ❑YES
BUIWING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOODZONE ❑NO EICHIEILHOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION:
100, 0Yo
By Iny signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have re4tdhfisapplication and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applordinances and state laws relating to w ding c:o or autthorizerepresentatives of Cupertino to enter the above-identified property for inspection
Signanrre of Applicant/Agent: LU �"�v Date. S'f3-fS
SUPPLEN%WrAL WORMAnON REQUHtED oz cE usE olv>Y
PRESS
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AMPArscApp 2OlLdoc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10106 LAMPLIGHTER SQ DATE: 05/13/2015 REVIEWED BY: MELISSA
APN: 342 33 001 BP#: *VALUATION: 1$2,900
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition /Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 REAP
WORK REPLACE E 125 AMP PANEL SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 125 Amps $48
TOTALS: $48.00
Xlech. Plan Check 1'lunah.Plan(:'heck Elec.Plan Check 0.0 1 hrs $0.00
allecla. MTllait&T: Plumb. Permit Pee: Elec.Permit Fee: IEPERMIT
Other Hech. Insp. Other Plumb Insp. Other Elea Insp. 0.0 hrs $48.00
<Llech.Insp.hee: Plumb. hasp. Fee: Elec.Insp.Ice:
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 prelhiniina information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff.711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. .P(�'1�ee
PME Plan Check: $0.00
Pennit Fee:
Suppl. Insp Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: (ADMIN $45.00
Work Without Permit? 0 Yes (F) No $0.00
Advances/Planning('ees:
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
'SUBTOTALS':`, $190.50 $0.00TOTAL FEE: $19 5 JO
Revised: 05/07/2015