10090171 CITY OF CUPERTI NO BUILDING PERMIT
BVILDiNC ADDRESS: 10119 S BLANEY AVE BLDG 15 CONTRACTOR:DEVERA PERMIT NO: 10090171
CONSTRUCTION INC.
OWNER'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 f-
�'�, �- BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class ' Lic.# '
(� j MECH RESIDENTIAL COMMERCIAL
Contractor Qs `'bl l c 2 : —Date 1^
j o
I hereby affirm that I am licensed under the provisions o Chapter 9 JOB DESCRIPTION: BLDG 15-APT B,D,F,H
DRYER VENTS:
(commencing with Section 7000)of Division 3 of the Business&Professions 1513-LAUNDRY&BATH FAN NOT VENTED TO OUTSIDE
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declaration:.:
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:$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'36903008.10119.15 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relati►.g WITHIN 180 3rS-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 DAYS F4"`tCALLED INSPECT ON.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, o _
costs,and expenses which may accrue against said City in consequence of the
Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by: .�
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
mature 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:
I 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 compensatic n,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors W 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
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 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,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent Date:
permit is issued.
I 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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I mt st 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 relati ig
building construction,and hereby authorize representatives of this city to enter
+i the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
iauemnify 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 CUPERTINO
4 ITEMS OF 40 PERM"T RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 3E903008 . 10119 . 15
DATE ISSUED. . . . . . . : 0S /20/2010
RECEIPT #. . . . . . . . . : BIE000011498
REFERENCE ID # 1C090171
SITE ADDRESS . . . . . : 1C119 S BLANEY AVE BLDG 15
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . :
OWNER LAKE BILTMORE APARTMENTS
ADDRESS 1900 S NORFOLK ST STE150
CITY/STATE/ZIP SAN MATEO, CA 94403
RECEIVED FROM . . . . : DEVERA CONSTRUCTION
CONTRACTOR . . . . . . . : HEVRY DEVERA LIC # 24605
COMPANY . . . . . . . . . . : DEVERA CONSTRUCTION INC.
ADDRESS . . . . . . . . . . : 941 D BERRYESSA RD
CITY/STATE/ZIP . . . : SAV JOSE, CA 95133
TELEPHONE . . . . . . . . : (4 )8) 441-9598
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- - --------- ----------
---------- ----------
1BCBSC VALUATION 300 . 00 1 . 00 0 .00 1 . 00 0 . 00
1BREMVENFA NO UNITS 4 . 00 84 . 00 0 . 00 84 . 00 0. 00
1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
----------- ---------- ----------
TAL PERMIT :
169 . 00 0 . 00 169 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-- --------------- --------------------
CHECK 1, 228 . 00 25049
---------------
TOTAL RECEIPT : 1, 228 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-----------
----- ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL
508 FINAL MECHANICAL
v CITY OF C-UPERTINO
CU PE TING GENERAL BUILDING
PEFMT APPLICATION FORM
�e7 6)`m/
APN #( Date:
Building Address:
10 I la SOUTH 13L.A N E V AVE N JE , UN►i S 15815 D 15 F 15 H
Mailing Address (if different from building address):
1015q SDUTH BLANEY AVENUE CUPERTINO , CA x50/4
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work onl ) Yes ❑ No If :s, provide letter from HOA
Owner's Name: Phone P:
PRONIETHEUS REAL ESTATE. 6RGU P q31- 3400
Contractor: Phone: ( 40g q141 -615,q S
' DEVLRA CDNSTRUCTIDN, INC- Fax: 640S 4ql -g379
Contractor License#: &4o f 1,
Cupertino Business License#: 24&b5
Phone:
Contact: 40 9) 401 -q561�
DEL. TOLAND Fax: 4cg 4q I -a3I S
Residential Commercial
Job Description:
UN rr 1513: LAUNDRY AND 13ATH FAN ,NC- VENT ED W1_610E
UNIr 150: LAUNDRY gXHAUSi VF-Nr AND FAN +5 Nor V'ENTED TL ourSIDE
UNI'r 15F: LAUNDRY EXHAUST VENT AN ) FAN 15 NUT VENTED TO OUrs10l✓
UNIT" 15H : LAUNDRY EXHAUST HOSE fn10 FAN IS Nd VENTED TO O(rsIDF_
Building Permit Info:
Bldg EK Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
u
1-A, 1-B ❑ II/III/V-A ❑ II/❑ B, IV- , V-F ❑ -�
Valuation: Square Footage:
$ 600. 00
Project Size: Express [] Standard ❑ Large [] Major ❑
Green Building: Please complete relevant portion c f the Green Building/LEED Checklist & attach it
to the application or if applicable. include in plan set & the sheet index.
Points Achieved:-
For help, contact Build it Green at www.bujldit!Zre!n.or
Revised 07/14/09
3