15090157 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20876 GARDEN GATE DR CONTRACTOR:BROSCOE ELECTRIC PERMIT NO: 15090157
OWNER'S NAME: JOSEPH EPPEL .;, Ell {c 5655 SILVER CREEK VALLEY RD#306 DATE ISSUED:09/23/2015
OWNER'S PHONE: 5209913285 SAN JOSE,CA 95138 PHONE NO:(408)223-8111
Ef LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMOVE(E)MAIN PANEL AND INSTALL(N)100 AND MAIN
License Class Lic.# `Q UC6.g k SERVICE PANEL
Contractor O,P_ C It c ,r,C_ 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.
I hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: Valuation:$800
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 APN Number:32630033.20876 Occupancy Type:
performance of the work for which this permit is issued.
2' 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. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPE TI .
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 n( f
upon the above mentioned property for inspection purposes. (We)agree to save Issued by: ` � Date: v`'
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 er the Cupertino Municipal Code,Section 9.18. ROOFS:
All roofs shall be inspected prior to anyy roofing material being installed.If a roof is
Signature c Date 'L� installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the
2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
i. I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
2. I have and will maintain Worker's Compensation Insurance,as provided for by or au horized nt: � �
Section 3700 of the Labor Code,for the performance of the work for which this A1A=e Date:
permit is issued.
3. 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If,after making this certificate of exemption,I
for which this permit is issued(Sec.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
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
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 Licensed Professional
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 t,50q() ��'� , MEP
Lo COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISIC
CUPERTINO (408)777-3228•FAX(408)777-3333• buildinclCa�cupertino.org
PLUMI3INGMECHANICAL LEC MCAL MISCELLANEOUS
PROJECT ADDREcc -Dy-' V Ct 1� APN#
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OWNERNAME �7 PHOONNE — E-MAIL
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❑OWNER ❑ OwNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CO*'Tn.ACTnR NAMELICENSE NUMBER LICENSE TYP BUS.LIC#�
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COM.EANYNAME E-MAIL FAX
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STREET ADDRESS, L CI STATE,ZIP C PHONE
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,Z PHONE
USE OF SFJ)or DUPLEX ❑ MULTI-FAMB.Y PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE ONO EICHLER HOME? NO
DESCRIPTION OF WORK
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TOTAL VALUATION: " - RECEIVED BY: Ln Oudy'4J
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pr perty owner's behalf. I have read this
application 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 applicable local
ordinances and state laws relating to building construct on. I authorize representatives of Cupertino to enter the above'-•identified property for inspection purposes.
Signature of Applicant/Agent: "�� nL -L,(& Date: es,
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO ISN01�.
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20876 Garden Gate Dr. DATE: 09/23/2015 REVIEWED BY: PAUL
APN: 326 30 033 BP#: *VALUATION: $800
PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 REAP
WORK Remove E main panel and Install N 100 Amp Main Service Panel
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 100 Amps $48
TOTALS: $48.00
rlech..Plcan Check 1'himb. Ilan C'hec/: Elec.Plan Check 0.0 hrs $0.00
Afech. Permit Fee: Plumb.Permit Fee: Elec. Permit Fee: 1EPERMIT
Otiter.'UecIt. Itn, ' Other Plumb lisp. LJ Other Elec.Insp. 0.0 hrs $48.00
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 preliminar information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution I1-053 E : 7/1/13) FEE QTY/FEE MISC ITEMS
%'last C hcc°l:1''ce:
uppl. PCFee
PME Plan Check: $0.00
ermit Fee:
Supl"?1. Insp Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construction Tax:
Administrative Fee: 1ADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
.,Idvanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $48.00
Strong Motion Fee: 1BSEISMICR $0.50 / Select an Administrative Item
E!t
ommission Fee: IBCBSC $1.00
SUBTOTALS: 1 $190.50 $0.00 TOTAL FEE: $190.50
Revised: 07/02/2015