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12090092CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10115 S BLANEY AVE CONTRACTOR: INTERNATIONAL PERMIT NO: 12090092 BUILDING INVESTMENT OWNER'S NAME: LAKE BILTMORE APARTMENTS 6117 GRANT AVE DATE ISSUED: 09/12/2012 OWNER'S PHONE: 6509313400 CARMICHAEL, CA 95608 PHONE NO: (916) 716-9565 ❑ LI ENSEONTRACTOR'S DECLARATION F_ r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. N S 5 MECH RESIDENTIAL r COMMERCIAL r Contractor Date 1 hereby afpr. that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: BLDG 27, UNITS A & B-LIKE FOR LIKE DRY (commencing with Section 7000) of Division 3 of the Business & Professions ROT REPAIRS Code and that my license is in full force and effect. THIS PERMIT IS FOR DRY ROT REPAIRS ONLY -NOTHING ELSE 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: $4500 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 permit is issued. APN Number: 36903008.10115 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We) agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 180 DAYS LAST CALLED INSPECTION. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 'L 9.18. Iss by: Date: Signature ___3x�Z ate ?11311L RE -ROOFS: ❑ OWNER -BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed. If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection, I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER construct the project (Sec.7044, Business & Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three declarations: [ have and will maintain a Certificate of Consent to self -insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation, as provided for by Section 3700 of the Labor Code, for the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & I have and will maintain Worker's Compensation Insurance, as provided for by Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code, for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued, I shall Health & Safety Code, Sections 25505, 25533, and 25534. 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 Owner or' agent: Date: ( 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. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued (Sec. 3097, Civ C.) correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit. Additionally, the applicant understands and will comply �— with all non -point source regulations per the Cupertino Municipal Code, Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION WADD.RESS: 5 S fiW1 DATE: 09/11/2012 REVIEWED BY: suewiAlbert PNBP#: "VALUATION: $4,500 a *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY Multi -Family Dwelling Buildina is PENTAMATION 1GENRES USE: 3 Stories © Yes Q No PERMIT TYPE: WORK LIKE FOR LIKE DRY ROT REPAIRS SCOPE NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the oreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 =# $467.00 Deck / Deck Railing IDECKRAIL Deck Railing Suppl. PC Fee: 0 Reg. Q OT 0.0 I hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. FeeQ Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 T-F 0 E) Work Without Permit? 0 Yes (F) No $0.00 Advanced Plannin Fee: $0.00 Select a Non -Residential Building or Structure G 0 i Strong 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