15030131 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10159 S BLANEY AVE CONTRACTOR–TBH—+"E PERMIT NO: 15030131
D
OWNER'S NAME: LAKE BILTMORE APARTMENTS DATE ISSUED:03/20/2015
OWNER'S PHONE: 6509313457 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
INSTALL TEMP POWER
License Class Lic.# Y
Contractor
Date 3
I hereby affirm that I am licensed under the provisions of C apter 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:
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:$200
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for performance of the work for which this APN Number:36903008.10159 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.I agree to comply with all city and county ordinances and state laws relating WITMN 180 YS 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 DAY 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 Issued by Date:c
granting of this permit. Additionally,the applicant understands and will comply
with all non-point sour c regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature ..�l�'n 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
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 sale(Sec.7044,
Business&Professions Code)
I,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
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 5 2K:Zate:
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:
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 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,I 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.)
Lenders 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 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 ARCHITECT'S DECLARATION
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
918.
Signature Date
GENERAL PERMIT APPLICATION 1
MEP
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION \�
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
(408)777-3228-FAX(408)777-3333-building(d)cupertino.ora MIS C
CUPERTINQ 0
❑PLUMBING ❑MECHANICAL LECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS /® /�`-� �4 ?� APN 11 9 03 06S,6
OWNERNAME (JPHONEk-aC/3 J 3 E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
CONTACT NAME
STREET ADDRESS 9n CITY,S�¢TP FAX
OWNER ❑ OWNER-BUILDER OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �,L LICENSE LICEN E TYPE BUS.LIC#
COMPANY NAME E-MAIL/ /y� / FAX
STREET ADDRESS / CITY,STATE , PHONE
6
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WHALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: Zw 3 fr
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provide 's 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 build' onstru I authorize repre&fttatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: A/� S
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SUPPLEMENTAL INFORMATION REQUIRED x^ o
F,i;ICEUSt ONLY
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„ ST�ARD✓ ,x...,..w
MEPMiscApp_2011.doe revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 101 69VI Blaney Ave. DATE: 03/20/2015 REVIEWED BY: GS
APN: BP#: `VALUATION: $200
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION 1 REAP14
USE: p PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $48
TOTALS: $48 00
tti
a
Mech. Plan Check Plumb.Plan Check Elec.Plan Check 0.0 hrs $0.00
L1ec1. Permit Fee: Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT
Ozh¢r alech. Inv, Other Plumb Insp. Li Other Elec.Insp. El"$48.00
t tfech. Insp. Fee: Plumb, hasp. Fee: 1-11ec.Imp,Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'1 info,
FEE ITEMS (Fee Resolution 11-053 E . 7/1113) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
,Supp P{.'Fee
PME Plan Check: $0.00
Permit Fee:
S�+ppl. InSIP Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Consti-nction Tax:
Administrative Fee: IADMIN $45.00
Work Without Permit? ® Yes (j) No $0.00
Advanced Planning Fees
Travel Documentation Fee: ITRAVDOC $48.00 i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
}
8 $190.50 $0.00 _� Q AL' F) E: $190.50
Revised: 02/14/2015
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Sheet Title:
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Utility Plan
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SD ----ji
F Job No. 20137096
-bbq • //1/777-/777777-/-j 19 January,2015
U.C. Date:.
Scale.
................. .......
1 �'7 f!1 7-
0/ Sheet No:
7i
IZI 17
C-401