11110159 (2) _ CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19500 PRUNERIDGE AVE BLDG 6 CONTRACTOR:MIKE ROVNER PERMIT NO: 11110159
CONSTRUCTION INC
OWNER'S NAME: IRVINE APT COMMUNITIES 1916 DUNCAN ST DA'Z'E ISSUED: 11/29/2011
NER's PRONE: 5103665302 SIMI VALLEY, CA 93065 PRONE NO:(408)453.6070
LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT'INFO: BLDG ELECT PLUMB
License Class_, Lia N P r r r
'Ni F"CII RESIDENTIAL COMMERCIAL
ContractorAA-P.e Datet6
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: BLDG 6-2ND&3RD FLOOR-REPLAC1724 WATER HI7ATER
(commencing with Section 7000)of Division 3 of the Business&Professions UNITS IN SAME LOCATION
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two 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. Sq.Ft Floor Area; Valuation:$275000
1 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 APN Number:31606037.BLDG6 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.1 agree to comply with all city and county ordinances and state laws relating W]TH AYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ,� rf I
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: <
with all non-point source regula'enSpCPtt Cupertino Municipal Code,Section
9.18.
RE;ROOFS:
Signature Dale it
Z 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.
- UII DF. F. 2 'f10N
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature ol'Applicant: Date:
the following two reasons; ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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)
1,as owner of the property,am exclusively contracting with licensed contractors to IIA%ARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California I Icalth&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Arca Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505, 5534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent; Date:
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 CONSTRU /0NLEN]KINGAGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked, work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.1 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 pRClll"1'FCT'S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
•,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records,
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
• 4 ITEMS OF 40 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31606037 .BLDG6
DATE ISSUED. . . . . . . : 11/29/2011
RECEIPT #. . . . . . . . . : BS000015424
REFERENCE ID # . . . : 11110159
SITE ADDRESS . . . . . : 19500 PRUNERIDGE AVE BLDG 6
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : IRVINE APT COMMUNITIES
ADDRESS . . . . . . . . . . : 550 NEWPORT CENTER DR
CITY/STATE/ZIP . . . : NEWPORT BEACH, CA 92660
RECEIVED FROM . . . . : MIKE ROVNER CONST.
CONTRACTOR . . . . . . . : MIKE ROVNER LIC # 31265
COMPANY . . . . . . . . . . : MIKE ROVNER CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 1916 DUNCAN ST
CITY/STATE/ZIP . . . : SIMI VALLEY, CA 93065
TELEPHONE . . . . . . . . : (408) 453-6070
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 275, 000 . 00 11 . 00 0 . 00 11 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1PRWHEATR UNITS 24 . 00 624 . 00 0 .00 624 :00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 723 . 00 0 . 00 723 . 00 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
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518 WATER HEATER
•