10090166 CITY OF CUPERTINO BUILDING PERMIT
BGIL151&G ADDRESS: 10109 S BLANEY AVE BLDG 17 CONTRACTOR:DEVERA PERMIT NO: 10090166
CONSTRUCTION INC.
NER'S NAME: LAKE BILTMORE APARTMENTS 941 D BERRYESSA RD DATE ISSUED:09/20/2010
OWNER'S PHONE: 6509313400 SAN JOSE,CA 95133 PHONE NO:(408)441-9598
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG� ELECT I- PLUMB
[�
License Class Lic.#�^l�(f t r
MECH RESIDENTIAL COMMERCIAL
Contractowg Date
JOB DESCRIPTION: BLDG 17-APT B DRYER VENTS-LAUNDRY FAN IS NOT
1 hereby affirm that I am licensed under the provisions of C apter 9 CONNECTED WITH THE HOSE
(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:
1 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:$300
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:36903008.10109.17 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 relatin€ WITHIN 180 DAYSE3F PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
O_,_ - -
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS OM LAST CALLED INSPECT ON.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued b Date:
i K
granting of this permit. Additionally,the applicant understands and will comply y'
with all non-point source regulations per the Cupertino Municipal Code,Section
19.18.
RE-ROOFS:
iature_ / � Date---- 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.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. as owner of the property,or my employees with wages as their sole compensatio►,
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 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 I 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 Area 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 25505,25533,aiW 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:_ Date: _
permit is issued.
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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code.l mu;t 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.I agree to comply with all city and county ordinances and state laws relatir g
iulding construction,and hereby authorize representatives of this city to enter
.►the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
I indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I 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 C JPERTINO
4 ITEMS OF 40 PERMIT RECEIPT OPERATOR: SylviaM
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36903008 . 10109 .17
DATE ISSUED. . . . . . . : 09/20/2010
RECEIPT # . . . . . . . • • : BS000011498
REFERENCE ID # . . . : 10050166
SITE ADDRESS . . . . . : 101(i9 S BLANEY AVE BLDG 17
SUBDIVISION . . . . . .
CITY CUPI�RTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : LAK, BILTMORE APARTMENTS
ADDRESS . . . . . . . . . . : 190 ) S NORFOLK ST STE150
CITY/STATE/ZIP . . . : SAN MATEO, CA 94403
RECEIVED FROM . . . . : HEN�2YADCONSTRUCTEVERA ION# 24605
CONTRACTOR . . . . . .
COMPANY . . . . . . . . . . : DEVERA CONSTRUCTION INC.
ADDRESS . . . . . . . . . . : 941 D BERRYESSA RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE . . . . . . . . : (408) 441-9598
FEE ID UNIT QUANTITY PMOUNT PD-TO-DT THIS REC- --NEW-BAL-
----------
------
300 .00 1 . 00 0 .00 1.00 0 .0
1BCBSC VALUATION 0 .00
1BREMVENFA NO UNITS 1 . 00 21 . 00 0 . 00 21 . 000 .00
1MPERMITFE FLAT RATE 1 .00 42 .00 0 .00 42 .00 0 . 00
1 .00 42 . 00 0 .00 42 .00
1TRAVDOC FLAT RATE ----------
TOTAL PERMIT 106 .00 0 .00 106 .00 0 .00
VOICE ID
DESCRIPTION VOICE ID DESCRIPTION
____
-- -----------------
03 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
3
503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL
508 FINAL MECHANICAL
~`v CITY OF CUPERTINO
cv�I�j � GENERAL BUILDING
PEPAUT APPLICATION FORM
APN # Date:
�`l C5 �F. XI C 1. 17 gl�s�zoio
Building Address: ' I`7
1010Q SOUTH (3 LA N F-V AVE
Mailing Address (if different from building address):
IC)IScl SOUTH 13L-AtJEY AVE, GJPEt2T'iNO, CA g501q
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes ❑ No If 1,es, rovide letter from HOA
Owner's Name: Phone#: (trp) q3t- 31400
PRnMET-HF-US REAL-- >;STA 1 E
Contractor: Phone: (X08) �I -q.SQ 8
DEVF-RA CpNSTRUL'rtON , INC• Fax: 408 t4�dt " q3�$
Contractor License#: 540'415
Cu ertino Business License*
Contact: Phone: (4p$)4�F1~ R5 Q 8
pal_ T'oLAND Fax: �►�D$ ��I- q3�$
Residential Commercial ❑
Job Description: 25
UNir LAUN.DRy FAN 6 NOT '_ONNECT&D WITH THE HG6E (TbO SHORT)
Building Permit Info:
Bld Elect ❑ Plumb ❑ Mech El
Type of Construction (Usage Class): Occupancy T e:
1-A, 1-B ❑ II/III/V-A ❑ U/M B, IV-HT,V-B
Valuation: Square Footage:
� 300. DO
Project Size: Express [�//Standard Large
Green Building: Please complete relevant portion of the Green Building/LEED Checklist. & attach it
to the application or if applicable, include in plan set & the sheet in
'oints Achieved:
r'or help, contact Build it Green at www.buildit een.or
Revised 07/14/09
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