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05080105 CITY OF CUPERI'INO BC4LDINC GSNIs10N FERN , CON'TRA'CTOR INFORM ON.$ BUILDING ADDRESS: PARAGON SERVICES/RGM BUIL ERIST"°05080105 10159 S BLANEY BLDG 16 OWNER'S NAME: PERMIT ISSUE DATE LAKE BILTMORE APARTMENTS 2812 TRINITY SQUARE DR 09/13/2005 NE: SANITARY NO. CONTROL N0. (972) 478-2255 ABUILDING PERMIT INFO RCHITECT/ENGINEER: - BLDG ELECT PLUMB - MECH 0 0 0 0 uoo LICENSED CONTRACTOR'S DECLARATION lob Description wp 1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing iW wit Section 7")of Division S ofta Business and Pordssiortx C6de.and my he...is '_.`z� imm�mreeandeffea REPAIR PLYWOOD CUTOUTS (3) License ClassLe.N Data Contractor CONTRACTOR: PARAGON SERVICES, INC ARCHITECTS DECLARATION dy 1 understand my plans shall be used as public records tau 3 0 1 Licensed Pndcssipwi S OWNER-BUILDER DECLARATION I hereby muc affirm dent 1 I.S.cBusin s an Ne Contractor's ssionslC i License c law for dee po which requires Permit t 7t13Ls.alter.improve ve deem Code:Any city or county 5m which rtquireaae,also to ansa Hepilar,improv.,h Permit to fireair any signedmmem ature riot ha its issuance,p.leu pursuant to the to applicant for such ramti0o ieIc a signed nammem deathcisliccnscJpursumtmlhcpmvisirnsnfdecCnmmner'sLiccnulaw(charter 9 Sq.Ft. Floor Area Valuati 4275 x�C (commencing with Section WWI of Division 3 of the Business and Professions Code)of i 5_Nat he is exempt barefoot and be bussu for Ne alleged exemption.Any violation of Section]031.5 by any applicant for aperoaitobjects toapplicant toacivil Rurally Of APN Number Occupancy Type not mora Nan Five hundred dollars(S500). 36903008 . 00 - 1,as owner of the property,or my employees with wages as Weir sole compensation, will do he work.and to structure is not intended or offered for sale(Sec.7064,Business Required Inspections and Professions Coal The Contractors License law does not apply m e an owner of _ q p prop'.,who builds or imprnves thereon,and who docssuch work hineselfor trough his �]rrr�� tt (� ryry own employees,provided tm such improvements are not intended oro@red for sale.If. �u t� /J';1 p however,to building or improvement is sold Wimin one year of completion,to owner- flit r "R".4�44 Frf� builder will have the burden of proving Nat he did not build or improve for purpose of J' a sae.). ❑1,as owner of to progeny,em exclusively crummu log wit licensed cone acmrs 1. ` construct dee projeet(Sec.7W,Business and Professions Code:)The Contractor's Li- 4'I 9 construct ecru Law does not apply to an owner of property who builds or improves Nemon,son who contracts for such projects wide aeontractor(s)licensed pursuant to he Contractor's do - Licc aJJ�s�.. F � 'T-- g. y sy, cytim'.craps under Sec ,B&P C for Nis reason i ' V �rt •.a t:,al�F�\�.\t1�.tJ'?'{t�j�^.,C''s�!'.s.�{t�b}��\J\/ er Dx¢ HN YSC�IQav Lw� ORKER'S COMPENSATION DECLARATION Ih by affirm under penalty of perjury one Otte following dedantions: ' 1 have and will maintain a Ccnifeam of Cmmm to self-insure for Worker's Compen- sation,ss provided for by Sectirn 37W of to Labor Cotle,for dee perfeimance of We OCT work for which Nis permit is issued. Q 7 2005 ❑I have and will maintain Workers Compensation Insurance,as requited by Section (v 37M of he labor Cons,for to paformance of Ne work for which his permit is issued. r�n CMy aWorker's Compensation Insurance camicrand Policy number am 11 )]11 IIT {} �.�., Carver. Policy No.: III1��JL{�ptlVlyt fp9L'_J tfrt]{ y`%=_ CERTIFICATEOF COMPENSATION I NFROM WORKERS' COMPENSATION INSURANCE ' mais section need not be completed if to permit Is for one hundred dollars(5100) It 1 comfy Nm in the performance of Me work for which this permit u issued,1 shall not cnployanypersoninanymannerat mhesubjfttmtMWmIeri Compensation Laws of California.Date�� ! Applicant NOTICE TO APPLICANT:IT after makidg this Cenificare of Exemption,you should became subject an dee Worker's Compensation provisions of Ne Labor Code,you must . .J O foMwit comply wit such provisions or Nis Permit shall be themed revoked. Z CONSTRUCf10N LENDING AGENCY F"(Z) Ihereby affirm tm t<re is aeonsractien lending agency for the performance of > Ne work cur which to permit is issued(Sec.3097.Civ.C.) [[4 A Lender's Namc Lenders Address U 0 1 cenify tat 1 have read tis zpplicaior and sure tat be above information is lL f" cancer I ague to comply with all city and county eminences and state laws relating to �U building construction.and hereby sutherne upassmntivcs of this city to enter Olen to r W ahove-mendoned property rot iuspecdor purlwses. (We)asree m save.indcmni ry and keep harmless deo City of Cu sheno against nF.d liabilities.judgments,costs and expenses which may in any way accrue against Said City of U z APPLICANT UNDEmccitunaOf do RSTANDSANDtbis rWILL COMPLY WITH ALL NON-POINT Issued by: Date 5 -ATIONS. 4 5 G Re-roofs Signamrc pplicanUComeactor Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will We applicant of future building=upon(store or handle haramous malarial as defined by to Cupertino Municipal Code.Chapter 9.12,and the Heart and Safely Code.Section 255324)7 Yea All roofs shall be inspected prior to any roofing material being installed. Cl j�jN l " Will mea applicant future building Occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove pp s e quipr Qu colt hvardnus air contaminants az defined by dee Bay Area Air Quality Management all new materials for inspection. District? Yes 1 have mad to hvardnus materials requirements under Chapter 695 or Na Califon ria Halt&Safety Cons,Sectiom 25X15.25533 and 25534.1 umlersmnd dw into harder, Jots not Comedy have a tenant Na it u my m5pnmibilo,m notify dee Occupant of tc regw C' UstMmatprior missuance oraeemficalaer panic. Signature ofApplicant Date Own roraudeorivcJagcnt Date All roof coverings to be Class "B" or better CITY OF CUPERTINO �m 15 of 16 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36903008 . 00 DATE ISSUED. . . . . . . : 09/13/2005 RECEIPT # . . . . . . . . . : 31168 REFERENCE ID # . . . : 05080105 SITE ADDRESS . . . . . : 10159 S BLANEY (BLDG # 16) SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : LAKE BILTMORE APARTMENTS ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : LAKE BILTMORE APART. CONTRACTOR . . . . . . . : BRYAN BROWN LIC # 27131 COMPANY . . . . . . . . . . : PARAGON SERVICES/RGM BUILDERS ADDRESS . . . . . . . . . . : 2812 TRINITY SQUARE DR CITY/STATE/ZIP . . . : CARROLLTON, TX 75006 TELEPHONE . . . . . . . . : (972) 478-2255 �EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- - - -------- ---------- --------- - ---------- BENERGYADD PLAN SETS 1 . 00 34 . 86 34 . 86 0 . 00 0 . 00 BPERMFEE VALUATION 1, 275 . 00 83 . 16 0 . 00 83 . 16 0 . 00 BSEISMICOM VALUATION 1, 275 . 00 0 . 63 0 . 00 0 . 63 0 . 00 BPLANCKADD PLAN SETS 1 . 00 34 . 86 34 . 86 0 . 00 0 . 00 - --------- -------- -- - --- ---------- TOTAL PERMIT 153 . 51 69 . 72 83 . 79 0 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- ________ ____--------________________ 101 FOUNDATION 102 PIERS 103 UFER 104 REBAR 105 ANCHOR BOLTS 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 203 UNDERFLOOR MECHANICAL 204 UNDERFLOOR FRAME 205 UNDERFLOOR INSULATION 301 ROUGH PLUMBING 302 TUB & OR SHOWER 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 305 FRAME 306 HOLDOWNS 307 INSULATION 308 SHEETROCK 309 EXTERIOR LATH 310 INTERIOR LATH 311 SCRATCH COAT 313 ROOF NAIL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY 505 FINAL ELECTRICAL 506 GAS TEST 507 FINAL PLUMBING 508 FINAL MECHANICAL 09 FINAL GRADE 510 FINAL PLANNING 14 FINAL PUBLIC WORKS eca A.S.E. 255 N. Market St . , Suite #220 San Jose, Ca. 95110 (408) 999-7441 Permit # 050800091 Thru 05080106 1 PLAN CHECK NUMBER: 05318 .CUP September 3,0, 2005 PROJECT: The Biltmore Structural Repair Details 10159 South Blaney Ave . Engineer: John Clinton 510-2360-7435 ------------------------------------------------------------- DOCUMENTS ATTACHED: VIA: 1 SETS OF DRAWINGS HAND DELIVERY Dear Sue: The attached document were reviewed and cleared by our office. 1 . Project engineer to inspect all repair works and to ® submit Structural Observation Report per note #7 of the plans . • CITY OF CUPERTINO cuPEi OF PERMIT APPLICATION FORM N # Date x Building Address: Mailing Address (if different from building address): Owner's Name: (/f,kj ,d/XT770AZ--/)f447; /..✓r-r Phone#: , 4, A614 1 orNO SiINSFT- /OGr Atuttp✓ �rlr ✓>a iv j.4 rle�j / a 4�5O S �53c5 V Contractor-Sva > License #: Gen/ SX% v c r S' /o Contact: Phone:9?-;Z y78adS Cupertino Business License#: Z,W,U ton_ Fax: ,g 7 Building Permit Info: i4 ; Bldg C' Elect ❑ Plumb ❑ Mech ❑ Job Description: ,BSCCA- /e y4Jc0,0 TO <ywcpo cc i o�T.r 19l (a8 Zoc v T/u~r To Residential p'ca i J°uTS 00�F!i 47-7-Ac H TFA/A C r Commercial ❑ Sq.Ft. Floor Area: AS rXis'T/Nc S/Sq.Ft.: Cost of Project: / Occupancy Group: ) / Type of Construction: Please check this box if the project is a T /9.c mss, O er° second-story addition: ❑ roject Size: Standard 2'-' Laze ❑ Ma'or ❑ 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 1M 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 tof3 f � � �� l G ( CITY OF CUPERTIN CUPEIZF PERMIT APPLICATION FTRM 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 BOVERTMIE 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 BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER InstaWAlter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 c$n MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo.Fumace> 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 De-vice/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREND1 EPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 OITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM Quantity Fee 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 BUELDING 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 Sucs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMTTFEE--_ —Plumbin -Peimit_Is"sue - — 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 C1 The411 ,.r. 10159 SOUTH BLANEY., CUPERTINO, CA 94/0 PHONE' (408) 255-8787, FAX (408) .255',014 the.biltmore®prometheusreg.com www.prometheusreg.co'R 4ry�(( 41, RfM T� T' OA DRIVEWAY 8 PARKING UREA/. PARKING �a Px , mtw Bomlgiv � �� m10fi tia— u +20oe6 � i. Y5. F'� F Bana,<1 � 1. ' roallw s � ImR+es voolqun �� r,. 3 mow . • I O Y � �Pll�}' 6�,.v, 2 � ne>� �_'C_ .; r '�� Nviwes '�`, � O � g� � • �'��:1 ,.: r� {{. '��5 Y�,r y �ryA .I ; Beq+�'.�'t t ,^�`r' cq � � t3K� • Ls-^^,fir � Y+'°�r��x�aw.a�vaA..5' "�'.�.Nt+. �r' - 3 ,„i 1 '@' 200]0 "oM°"' .,,ZX_ loin a . m >•'�i': s POOL " . s"` r" v }01] • s.Bw m . PARKING "� ' Baanave: t. `vvVS 1ot1s PARKING w. 18129 • z 20 N.a i h+3?1 pqp Outs '� F»L_ >'� u.: .-.i � €•.t'J++1 Yy� � 3 G.,r'VG�eG IOIW 9.BWry 2w16 a t� f7 S... � /•� 1 (�* ��$;`+f� • Poaawn � � k�' >fp ,stn"' 3} '' 'i*, i� t�++vn� ?ii,r7P'".674 1 =1� ,�5,�yy' ta'��'��tj' �? �is ws- -i -oM "Y}yY 10149 r^1yreD� .sm N}:+ 1.� .� lt ZI ; 533 ,kr$ ^' 10169s.BbntY �yH}ly�k 101]9s BUrcr } s3 t 1 ..4•.',SM��`+v'Y>52uf�'�n�.'�.."�`Afi��a� u.. .f"�¢rCc.-sY+i:s"1.^1:r4kuII...la�ll`-�.. �:�::�^�i''+...::3.# / S. BLANEY .AVENUE r i IN-TERACTIVE R. E 'S O U R C E S FAX TRANSMITTAL PAGE 1 OF 5 Date: July 29, 2005 (650) 570-4380 To: Chris Larsen (�`/C��, 117 Park Place Prometheus [E `� IED vM E Point Richmond California 94801 1900 South Norfolk Street, Suite 230 510-236-7435 San Mateo, CA 94401 AUG _ 2 2005 Fax 510-232-5325 www.intres.com Architecture Engineering Planning cE Construction Review r � From: John Clinton, SE, AIA Failure Analysis 1 Subject: The Biltmore AUG 2 200 5 Contract: 2005-044.01 Via: X❑Fax F-1 For Your Information • XO US Mail ❑For Your Approval Overnight Mail FIFor Your Review and Comment courierX❑As You Requested ❑Pick-Up FlAs Indicated Materials Transmitted: Two copies of letter and repair drawing for correcting over sized plywood cut made to allow access to a clean out. The drawing is 11 x 17 original size. Cut it in half to fax. raS PLAN SHALL REMNN ON (HE JOB AT ALL TIMES =BSS CONSMUCTM, Project O The documents accompanying this telefax communication contain confidential information which may be legally privileged. The information is intended only for the use of the intended recipient named above. If you are not the intended recipient, you Correspondence❑ are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on the contents of this telecopied information except its direct delivery to the intended recipient named above is strictly prohibited. If you have received this fax in error,please return the original documents to us. INTERACTIVE R E ' S 0 U R C E S ® � Arehircchme Engineering Planning Consrructian Rcvinw Failure Analyai` July 29, 2005 Principals: Chris Larsen Thomas K. Burt,FAIA Prometheus A,,h""` 1900 South Norfolk Street, Suite 230 John E.Chnren,SE,AIA San Mateo, CA 94401 Simaur.J Li,,A,hl,,,r Charles L. Beavers,AIA Subject: The Biltmore Apartmens 2005-044.01 A"i"r"` 10159 South Blaney, Cupertino, CA Edw:ud J.Anisnum,.AIA A,d""" Dear Chris: Sharon Wat ,rn,mn,AIA Amhnca A site visit was made to subject apartments to review the cutout in the plywood D<,nmld A.Cu<hmg,Jr.,PE,SF wall sheathing around existing waste pipe cleanouts. The building inspector asked "... nJ""`""" that a structural engineer design, detail, stamp and sign the proposed repair. Ayj�v M. Bwq AIA,LEED AP ® A"ha-' Observations Cal Chooey,AIA A,ci,°°cr 1. There are reportedly 28 holes to be repaired. George Y.Namkang,AIA 2. After reviewing the 4 holes, it appeared that we had seen a representation of Archir,ct all the opening conditions on the project. 3. One of the problems is the lack of space to install edge blocking around the cast iron pipes with edge blocking. 4. Sheathing is 15/32 inches 117 Park Place 5. Edge nailing appeared to be 8d at 4 inches on centers. Field nailing was not Point Richmond reviewed. California,94801 510.236.7435 Solution Fax 510.232.5325 wrrw;�ures.ann No drawings were available, therefore we assumed shear wall shear wall conditions to determine if the holes are in shear walls therefore we were unable to ignore the condition and make cosmetic repairs. Since all of the hardboard siding would be removed from the base of the wall to above the cut it will be reasonably simple to provide a structural repair to be equal or better than he wall in which the repair is made. See attached sketch for parameters. Chris Larscn July 29, 2005 Page 2of 2 • Thank you for the opportunity to assist you on this project. Please call me if you have any questions OFESS/ON S e e-. C h _ 2 Z w w 9-30-05 M tN M, � s nWJG. G S'T STRUCT091 grFOF CAUFOP CITY OF CUPERT[NO •x.�„^� "'�"£ _ k 'R ` BUILDING DIVISION PERMITkCONTRACTnR`INFORMATION "'' BUILDING ADDRESS: PARAGON SERVICES/RGM BUILrEER^SI�NO05080105 10159 S BLANEY BLDG 16 NER'S NAME: PERMIT ISSUE DATE LAKE BILTMORE APARTMENTS 2812 TRINITY S UARE DR 09/13/2005 NE: SANITARY NO. CONTROL NO. (972) 478-2255 ARCHITECTIENGINEER: BUILDING PERMIT INFO ' BLDG ELECT PLUMB MECH I� 0 u00 LICENSED CONTRACTOR'S DECLARATION lb Description w I hereby affirm NoP at 1 am licensed under provisions of Chapter 9(commencing < r usforcea deffecDivisionJafthBusiness,na dProfcuinnaC6d .andmylicenseis � nREPAIR PLYWOOD CUTOUTS (3) nwaxa :Lk. CONTRACTORPARAGON SERVICES II(Jh, uaa ,NC` t' 1 -Fp Date Contractor x VLJ` .F21 ARCHITECT'S DECLARATION 5 u l I urnscrsund my plans shall he used as public rocoms roti Licensed Professional 2U05 ` g OWNER-BUILDER DECLARATION E 0 R 1 hereby affirm Out 11. exempt from the Goths Co License city o for the (�f(1 l 11 Tr)g kg p0 following moon.(SccuoI 7(131.3,e. Its, and improve, foes Code:Any city r(county I'-'J('lU' fy' Km whichrequiresapermitreuirestea@rintfor sdh permits fie a signedny swment Y�< cture aurora its issuance.also requires the applicant for such permit filcasigncJetaumcm - Out Mu islicensedpursuanothe provisions ofthe Contractor's License Law(Chaa¢r9 Sq.Ft. Floor Area Val'u5[i d.2-7 yFG (commencing with Section 70()(b of Division 3 of the B usincxs and Professions Codc)or Q Nnt at he Is exempt thcrtfroand de boo for the alleged exemption.Any violation of Section 7031.5 by any applicant for a pcxmitSubjects thc applicant to acivil penalty of pPN Number Occupancy Type nod mon thW five hundred d.11.(S500). 3 6 903008 . 00 ❑l.sowncrk,and pro perty,umyemntendc with vnguudlel(wle compcnutiess will do Newark.ander xtrununtis not intendedoraw dos.1a(Sec.7044,Buinm and anywh ons Codc:The Contractor's ndwho Taw does amt apply if ,t mucor is Required Inspections property who b.provided tions thereon,and who doesauch wort himselfedlhrougM1 his own employees.provided th mwmimprovements are not intended m offered tre owner- Wilder however,Ne building or men o wment is hatd within ore year or improv for the rwmr- .ilder will haw Ne buNrn of proving Nos M1c did not build or improve far Puryo.¢of sale J. ❑1.as owner of the property,am exclusively contracting with licensed contractors to convect the project(Sec.70W,Business and Professions Codc:)The Contractor's Li- cense taw does not apply to an owner of property who Wilds or improves @croon.and who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's Lj-nLuen m exempt under Sec. .B k P C for this mason crDau—� ORKER'S COMPENSATION DECLARATION 1 by aRinn under penalty of pe(ju(y one of the following declarations: 1 have and will maintain a Cenifieeu of Consent to self-insure for Worker's ComKn. cation,u pmvided for by Section 3700 of the Labor Code,for the performance of the wart(or which Nix permit is issued. ❑I haw and will maintain Worker's Compewtion Insurance,as retained by Secuon 3700 of Ne Labor cods.for the performaxrcc of the work for which this permit is issued. My Worker's Competuation Insurance anis and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not Mcompleted if the Immix Is for one hundred dollars($I00) or Icss.) I cenifv Out in the Performance of the work for which this permit is luted.1 shall not employ any pawn in any manners�mbecoryceub(1.the Worker,Compensation Laws of California.Du 0 / �� Applicant a NOTICE TO APPLICANT:If,after maknIg this Certificate of Exemption,you should become subject to Oc Worker's GoroIICroUdOn provisions of ohs labor Codc,you must .J z forthwith comply with such provisiotu or Nis Permit shall W deemed revoked. z O CONSTRUCTION LENDING AGENCY [-. I hereby Mo.Nat there is a construction lending agency Lor ths performanceof 'Y f work for which this panni`is issued(Scc.3097,Ci,C.) GA Lendcls Namc 7 z Lend2Addo:ss U O 1 certify Nat I haw lead this application and sum that the&bow information is By P emocel.I agree to comply with all city and county ordinances and sum laws relating to C U building convection.and hereby authorizenpresentanves of this city to toter divan the r W above-mentioned property for inspection purposes. (-'0. (We)agree to save,indemnify and keep hornless the City of Cupertino against liabi lines.judgments,costs and expenses which may in any way accrue against said City U in consequence of the granting of this permit. / %i/ '-" APPLICANT UNDERSTANDS AND WILL COMPLY WITI)ALL NON-POINT Issued by:9 Date 7 J V S 'ATIONS. 4 �� C Re-roofs Signazum ppiicanUContnctor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the."licand of future building occupant atom or handle haaandous material u defined by the Cupsnlno Municipal Code.Chapter 9.13.and Ne Health and Safety We, S. 25632(a), All roofs shall be inspected nor to an roofing material beim ❑res y� P P Y g g installed. Will the applicant or future Wilding occupant esu cyviamcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove mix ba(ardous air contaminants as de0ned by Oc Bay Arta Air Qualiry Management all new materials for inspection. District, ❑Yea 1 have road the ha dN ius maurialsmquimmenu under Chopwr6.95 of Ne Califon nix HaIN&Safcty Coda Sea=25X15.25533 and 35534.1 un&n=d thwif thc building docs not currently have a Worm Nat it is my responsibility to noufy the metaled of the reyui '/ usthcmet prior to issuance ofaCcreficateopane. SignatureofApplicant Date Own nthaimd agent Dam All roof coverings to be Class"B"or better