11110119 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10204 PARKWOOD DR CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 11110119
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED: 11/22/2011
( R'S PHONE: 6509618330 SUNNYVALE,CA 94086 PHONE NO:(408)806.9145
LICENSED CONTRACTOR'S DECLARATION f r
BUILDING PERMIT INFO: BLDG "- ELECT ' PLUMB
License Class Lic.# r r' r
MECH RESIDENTIAL COMMERCIAL
Contractor aQc4=�/E((C(r7c. t Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:MULTI-FAMILY WINDOW REPLACEMENT(28)
(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:
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:$20000
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
permit is issued. APN Number:32627037.10204 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
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, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source r gulatians per the Cupertino Municipal Code,Section Issued by. - D.0
)�/ /
Signature - Date,
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm That 1 em exempt from the Contractor's License Law for one of installed withoia first obtaining an inspection,I agree to remove all new materials for
y P inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 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 1 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 shell Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Ow ri agent:
Compensation laws of California. If,after making this certificate of exemption,l Date: e�
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.1 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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
iftnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
iiiiiiiiiiiiiiiiiiand expenses which may accrue against said City in consequence of the
Ming of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
• CITY OF CUPERTINO
3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 32627037.10204
DATE ISSUED. . . . . . . : 11/22/2011 _
RECEIPT #. . . . . . . . . : BS000015372
REFERENCE ID # . . . : 11110119
SITE ADDRESS . . . . . : 10204 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
---------- ------------- ---------- ---------- ---------- ---------- ----------
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
1WINREP EACH 8 28.00 782 . 00 0. 00 782 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 785. 00 0 . 00 785 .00 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT
------------------CREDIT CARD 1,243 .50 VISA
---------------
TOTAL RECEIPT 1,243 .50-
•
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333• buildinG(o4cuD^rtino.orG
NEW CONSTRUCTION ❑ ADDITION _1710N/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
Ro1ECTADDRPS9 AIN$
d U (J
OWNER NAME/�V&n y G't_t Na ( L, P PHONHdl-O-96/-Fl H AVG'rK
P ,,ecA .t.��
CONTACT NAME P ONB E
StC:✓t,- r?'UAeaGtC. �DAS-$o6' Ln.J Mn- 4v
STREET ADDRESS III CITY, ATN ZIP U P
❑OWNER ClOWNER-BUILDER ❑ OWNER AGENT 4YCONTMACTOR E3 CONTRACTOR AGENT13 ARCmTELT 13 ENGINEER. 13 DSYELOPFa C3 TENANT
CONTMCTOR NAME e C L`y LICENSE NVA♦H L !6 (76 TICENSE TYPE BUS.LIC 0
COMPANY NAME H•MAH. �'( P !/a3- C4 Wo
7- ^ )
e.re- >7 S e to 00L) OV . Ma d d),M
STREET ADDRESS .STATE ZIP Tc'
ule L v 6— S
ARCH37ECT/BTNGNEERNAa4: a ) .,L LICENSENUREBER am.LIC0
COMPANY NAND? l� P� E-MAIL FAX
STREET ADDRESS CTTY,STATE,ZIP PHONE
DPSCRIP ION OP WORT
SOSTDIG USE PROPOSED USE CONSTILTYPH SS RyiH4
_ _ ` USE TYPE OCC. SQFf. VALUA-nON(5)
AREA ARE PL000. DEMO TOTAL
ARRA ABPA ARRA NET ARRA
0TNR00M KITCHEN OTBBR
REMODELAREA RPMODELAREA REMODEL AREA
PORCHAREA DECRARPA TOTAL DECK/PORC'H AREA GARAGEARPA: DETACH
ATTACH
A DWELLING UNrrs; t9A SRCONDUNR YES SECOND STORY YES
a@'G ADDED? NO ADDMOTO NO
PR&APPLLGT[ON BYES ff YES,PROVIDH COPY OP fa THE BLDG AN ❑YE7 RECEIV®HY: TOTAL VALUATION:
PLANNING ADPL/ NO PLANNING APPROVAL LHRER SICBL.BR HONERT NO
Zdr ooU
By my signature below,I certify to each of the following: i sm the property owner a authorized agent to act on the prpperty owner's behalf. I have read Us
application and the information I he v'tied is correct I have read the Description of Work and verity it is accurate. I agree to comply with all applicable local
ordin®ca and state lam relating ding c dart. I authorim represrntativa of Cupertino to anter the abov idendproperty for inspection purposes.
Signatum ofApplicant/Agenn Dam; a
SUPPLEMENTAL INFO TION REQUIRED PLAN CHICHTYPB ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for 13,-01'rM,r>$-COUNT R. C- aaU DING PLAN RZVMW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ svRxw ❑ PLANNING PLAN RHVDrw
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
To—rut if any Hazardous Materials are being used as part of this project. ❑ LARGI ❑ Fm inarr
Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MANOR ElSANITARY SEWER DLSTRICT
bmittal of Building Permit application.
❑ ENVmON110981TAL RRALTH
BldgApp 201 Ldoc retired 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
• MI
ADDRESS: 10204 parkwood DATE: 11/22/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $20,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY Multi-Family Dwelling Buildlna is PENTAMATION 1GENRES
USE: 3 Stories O Yes 0 No PERMIT TYPE:
WORK multi-family window replacement.
SCOPE
dfrr4 Pi.n:Chrrk PLanL. Plan Check Elee.111('11 ChscA.
blevh. Permit lore: Plundr. llernw Fee: E:lee. Perneir Fee:
olher'U'v1J.Insp. (Vur Plumb Lisp. Li (bher Eier:. hup. Li
Mcch.In,ep.Fee: Pluwl, brop.Pae: Mee.Inrp, 1'ee:
NOTE: This estlmale 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 prellidna information available and are only an estimate. Contact the Dept for addn7 infa
FEE ITEMS(Fee Resolution 11-053 Eli' 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Window/Sliding Glass Door
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $652.0011 EP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Con irneflan nix
(dnuni.sfnuis"Fee: O
Work Without Permit? C) Yes 0 No $0.00
Advanced Planning-Fee. $0.00 Select a Non-Residential
Travel
17ncurnen/cuiore F'eus: Building or Structure 0
StratC Motion Fee: IBSEISMICR $2.00 Select an Administrative Item ^
• Bldg Stds Commission Fee: IBCBSC $1.00 9
SUBTOTA] $3.00 $652.00 TOTAL FEE: $ 5.00
Revised: 1C(/01/2011
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
U P E RT I N O Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 6 a 6 4 PERMIT#
OWNER'S NAME: Pr Con u PHONE
GENERAL CONTRACTOR: -evC (evaveat Cons BUSINESS LICENSE#
ADDRESS: p CITY/ZIPCODE: ✓d
le, CA-
*Our municipal code requires all businesses working in the city to have a City of Cupertin business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND A=UBCON CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: all
Signature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass /Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date