12090072CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10149 S BLANEY AVE
CONTRACTOR: INTERNATIONAL
PERMIT NO: 12090072
BUILDING INVESTMENT
OWNER'S NAME: LAKE BILTMORE APARTMENTS
6117 GRANT AVE
DATE ISSUED: 09/12/2012
OWNER'S PHONE: 6509313600
CARMICHAEL, CA 95608
PHONE NO: (916) 716-9565
❑ LICENSED CONTRACTOR'S DECLARATION
r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. t✓ V % �2
r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereb a irm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: BLDG 3, UNITS B,D,F,& H-LIKE FOR LIKE DRY
(commencing with Section 7000) of Division 3 of the Business & Professions
ROT REPAIRS ONLY
Code and that my license is in full force and effect.
NO GUTTER/DOWNSPOUT REPLACEMENT(THIS INCLUDES BEAMS
I hereby affirm under penalty of perjury one of the following two declarations:
& FASCIA) OR CONSTRUCTION OF MISSING PATIO ENCLOSURES TO
I have and will maintain a certificate of consent to self -insure for Worker's
MATCH EXISTING ONES UNTIL DIRECTORS MINOR MOD IS
Compensation, as provided for by Section 3700 of the Labor Code, for the
APPROVED BY PLANNING
performance of the work for which this permit is issued.
I 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
Sq. Ft Floor Area:
Valuation: $4500
permit is issued.
APPLICANT CERTIFICATION
APN Number: 36903008.10149
Occupancy Type:
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non -point source regulations per the Cupertino Municipal Code, Section
180 DAYS M LAST CALLED INSPECTION.
9.18.
Signature_ Date
Issu d b /TJt/ Date:
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
All roofs shall be inspected prior to any roofing material being installed. if a roof is
I, as owner of the property, or my employees with wages as their sole compensation,
installed without first obtaining an inspection, I agree to remove all new materials for
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued, I shall
contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, I
Health & Safety Code, Sections 25505, 25533, and 25534.
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
Owner V-51-Uiborized agent: f
Date: /J 2-
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws relating
1 hereby affirm that there is a construction lending agency for the performance of work's
to building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (See. 3097, Civ C.)
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Lender's Address
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9
ARCHITECT'S DECLARATIQN
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
S BLANEY AVE
DATE: 09/11/2012
REVIEWED BY: suew/Albert
4WADDRESS:/Q/
APN:
BP#: /p��
'VALUATION: $4,500
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY Multi -Family Dwelling
USE:
Buildina is
>3 Stories 0 Yes 0 No
PENTAMATION 1GENRES
PERMIT TYPE:
WORK
LIKE FOR LIKE DRY ROT REPAIRS GUTTER/DOWNSPOUT REPLACEMENT & CONSTRUCT
SCOPE
MISSING PA-1-10 ENCLOSURES TO MATCH EXISTING ONES
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
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FEE ITEMS (Fee Resolulion 11-053 Eff 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 #
$467.00
Deck / Deck Railing
IDECKRAIL Deck Railing
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg.
Q OT
1 0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
Work Without Permit? O Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
Stroniz Motion Fee:
IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$467.00
TOTAL FEE:
$468.50
Revised: 07/01 /2012