11110040 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10200 PARKWOOD DR CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 11110040
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED:1110812011
R'S PHONE: 6509618330 SUNNYVALE,CA 94086 PHONE NO:(408)806-9145
❑/ LICENSED CONTRACTOR'S DECLARATION ( r I_!
r.� BUILDING PERMIT INFO: BLDG - ELECT PLUMB
— - — ---— - -----
L_icense Class MECH Lic.B I- r
_! RESIDENTIAL '- COMMERCIAL -
C_on_tra_etor_312t.eP/e DC(K�a Date _ __ -
- - JOBDESCRIPTION: MAIN BLDG-R-2 COMPLEX RPLACE 12WrNDOWS;
1 hereby affirm that 1 am licensed under the provislons of C apter 9 NONSTRUCTURAL
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license Is in full force and effect.
1 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$20000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:32627037.10200 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and slate 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accme against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-poi source regulatims per the Cupertino Municipal Code,Section
9.18. Issued by: Date//Signature:
ate//
L-
ignature _ Date
9FOWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that 1 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
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE.
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 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&Safely Code,Sections 25505,25533,and 25534. I 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(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
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 ll
Compensation laws of California. If,after making this certificate of exemption,I Ownel Iho ed glnt:
become subject to the Worker's Compensation provisions of the Labor Code,I must -----%1 Date:
forthwith comply with such provisions or this permit shall he deemed revoked. - - -_.-._ .. - "
CONSTRl1CT10N 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
nhfy and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
gr ting 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
• - i
• CITY OF CUPERTINO
4 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot: '
APN . . . . . . . . : 32627037. 10200
DATE ISSUED. . . . . . . : 11/08/2011
RECEIPT #. . . . . . . . . : BS000015261
REFERENCE ID # . . . : 11110040
SITE ADDRESS . . . . . : 10200 PARKWOOD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : AVERY GLENBROOK LP
ADDRESS . . . . . . . . . . : 130 E DANA ST
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94041-1508
RECEIVED FROM . . . . : STEVE P PLEVANCIC
CONTRACTOR . . . . . . . : STEVE PLEVANCIC LIC # 32967
COMPANY . . . . . . . . . . : STEVE PLEVANCIC CONSTRUCTION
ADDRESS . . . . . . . . . . : 528 S MATHILDA AVE STE 2
CITY/STATE/ZIP . . . : SUNNYVALE, CA 94086
TELEPHONE . . . . . . . . : (408) 806-9145
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 .00 41. 00 0. 00 41 .00 0. 00
1BCBSC VALUATION 20, 000 .00 1. 00 0. 00 1. 00 0. 00
1BSEISMICR VALUATION 20, 000 .00 2. 00 0. 00 2 . 00 0. 00
1STINSP UNITS 1 .00 130. 00 0. 00 130 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 174 . 00 0. 00 174 . 00 0. 00
•
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)7777-3333•buildinG(acuoertino.orn
7sTRE❑NEW CONSTRUCTION ❑ ADDITION 1G1 ALTERATION/TI ❑ REVISION/DEFERREDEDt ORIGINAL PERmrr N
Err
POIE17ADDREII 0 &-too H^ AFNM� /_ "t, 0 3.7, /0 � -) .
OWNER NAM¢4VtoY G2C-' a je L, � PHO76-6-96/-k? O B��L''7L'fS (Miu•k�
00 lh uA ��SS ov�✓Lvt�.lU 1 eA-1 CN
CONTACT NAME PT�qO
St '"Jl- CUArJCtt" YOff-$06' *)-t' E-
t•" A LLL) Mn. � 4v
STREET ADDRESS id CITY, ATE, IIP F
cl-- n U -
141 ca
❑OWNER 13OWNER-BUIDER ❑ OWNEI AGENT 11YC//ON RACTOR ❑CONTRACTORAOENT ❑ ARcEnEcT ❑aNcumes. ❑ DEVELOPER ❑TENANT
CONTRACTOR N' e C{- LICENSE NUMB 46
6 56oT10EN38 TYPE BUS.LIC N
COMPANY NAME 2'r2. „Llc e•MA¢s e v Q u 17a C. »I P
STREET ADDRESS b cl y1 .9TAT$IIP ONB
T �2 G. V -S
MCHITECr/FNOafEERNAME , 7 .A_ LICENSENUMBER BUB.LICP
CONTANY NAME ,v B-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORE
v
PROPOSED USE CONSTRTYPH MS ArUBE TYPE OCC. SQFT. VALUATION(5)
TOTAL
AM R � AREATno
OTHER
AEMODE,AAEA REMODEL AREA 0.EMOOE.AREA
PO0.CH AAM DECKAREA TOTAL DECIVPORCH AAEA EMUS AREA: D61'ACH
ATTACH
Y DWELLING UNITS: OA SECOND UNIT H YES SECONDSTORY yEs
BE14G ADDED? NO ADDITTON1 NO
FRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS TER BLDG AN ❑YES gECEIV®BY: TOTALZ' VALUATION:
FLANNINOMPL/ NO PLANNING APPROVAL LETTER ECHLER RON" d0
dr oo0-=
By Dry signanue below,I certify to each of the following: I am the property owner a authorized agent In act on the prWerty owners behalf I have read this
application and the infbmiWI he sided is correct I have read the Description of Work and verity it u accurate. I agree to comply with an applicable local
ordinances and state laws relating ding on. I authorize representatives of Cupertino In anter the above-i pm arty for inspection purposes.
Signatm of ApplicandAge tt Dern:
SUPPLEMENTAL INFO TION REQUIRED PLAN CHECK ROUTING 3JP
New SFD or Multifamily dwellings: Apply for demolition permit for TT ,,.�,, �
L7'OVQ;-TBC@f
ROr� LF'RUII.DING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ UMUMS ❑ PL&NMG H AN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ srANDARD ❑ PUBUC WORKS
form if any Hazardous Materials are being used as part of this project ❑ LARGE ❑ Ftax bxrr
Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT'
hmittal of Building Permit application.
❑ F-NVIRONMENTAL HEALTH
B1dgApp 1011.doc revised 06/11111
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
• ADDRESS: 10.200 parkwood DATE: 11/08/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY Multi-Family Dwelling BUIIdIn41S PENTAMATION
USE: y g >3 Stories 0 Yes (j) No PERMIT TYPE:
WORK r-2 com lex replace 12 windows non structural
SCOPE
.tie,rrr. PLvr Clark Phmrb.Plan Check ilea_Piart Check
,Veuh. Per:ait pec: Plunth.Pernit 1'arc ?-'i.f. F''ern;i:Rae:
orhe,,Meeh.bap. Other Phemb by p. ED Otlrca l:.hv.. hmp. Li
Af•rh.Inep. Ree: Plumb. ln.vp.Ycc: Gan, Imp. Fce:
NOTE: This estlmate does not include fees due to other Departments(ie.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelinina Information available and are only an estimate. Contact the Dept for addn'l Info.
FEE ITEMS (Fee Resolution 11-053 Elf, 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: t,7 Reg. () OT 0.0 hrs $0.00 7-71 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly Only? Q Yes 0 No $0.00
Suppl. Insp.Fee-.0 Reg. Q OT 0.0 his $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Telt:
Administrative Pre: Q
Work Without Permit? C) Yes 0 No $0.00
Advanced Planning Fee: $0.00 = hours Inspections
Travel Docruneniatirm Veay. $130.00 ISTINSP Inspection,Hourly
Strong Motion Fee: IBSEISMICR $0.50 0.5 . 1 his Admin./Clerical Fee
• Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 (ADMIN
SUBTOTALS: $1.50 $171.00 TOTAL FEE: $172.50
Revised: 10/01/2011