12010101CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10230 PARKWOOD DR CONTRACTOR: STEVE PLEVANCIC PERMIT NO: 12010101
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED: 01/13/2012
OWNER'S PHONE: 6509618330 SUNNYVALE, CA 94086 PHONE NO: (408) 806-9145
0 LICENSED CONTRACT/O�R'S DECLARATION
License Class Lie. # '7
Contractor hryetV41C 64 Date
I hereby affirm that I am licensed under the provisions of Chapter 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 Iserjury 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.
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.
APPLICANT CERTIFICATION
€ 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,
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 cations per the Cupertino Municipal Code, Section
9.18.
Signature Date �� /�
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business & Professions Code).
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH ' RESIDENTIAL _. COMMERCIAL'
JOB DESCRIPTION: 5 REPLACEMENT WINDOWS, EGRESS COMPLIANT
Sq. Ft Floor Area:
Valuation: $5000
APN Number: 32627037.10230 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAPS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date:
RE -ROOFS:
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 rernove all new materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
I have and will maintain a Certificate of Consent to self -insure for Worker's California Health & Safety Code, Sections 25505, 25533, and 25534. I 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 I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by 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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued. Health & Safety Code, Sections 25505, 25533, and 25534.
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 Owt r a o ed agent:
Compensation laws of California. If, after making this certificate of exemption, I Date: -3
becorne 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 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
indemnity and keep harmless the City of Cupertino against liabilities, judgments,
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 regulations per the Cupertino Municipal Code, Section
4.13.
Sianature Date
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32627037.10230
DATE ISSUED.......: 01/13/2012
RECEIPT #.........: BS000015752
REFERENCE ID # ...: 12010101
SITE ADDRESS .....: 10230 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
----------
5,000.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1BSEISMICR VALUATION
5,000.00
0.50
0.00
0.50
0.00
1WINREP EACH 8
5.00
392.00
0.00
392.00
0.00
TOTAL PERMIT
----------
393.50
----------
0.00
----------
393.50
----------
0.00
CITY OF CUPERTINO
_ FF,F, F,'i�TIMATOR — RTTII DING I)TVISION
ADDRESS: 10230 parkwood
DATE: 01/13/2012
REVIEWED BY: larry s
APN:
BP#:
VALUATION: 1$5,000
PERMIT TYPE: Building Permit
PLAN CHECK TYPE:
Alteration / Repair
PRIMARY Multi -Family Dwelling=�.13
USE:
uildina is
Stories d Yes (j) No
PENTAMATION 1 GENRES
PERMIT TYPE:
WORK
4 replacement windows egress compliant
$0.00
SCOPE
$0.00
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer Distriet, School
n:.,i..: i ..i.. 1 Tt., . F —1. l.. —1 __ il.., r.rn/i.s.s.nw.. icif n niin.. mrni/n/./e nnd nr nnhf "" octimato Cnntnpi tho Dont fnr i,4dn'l info_
FEE ITEMS ;'.. 'rs. ,"F: „ f ' }/11
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00F$392.001
#
Window / Sliding Glass Door
IWINREP Replacement
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
0.0
hrs
$0.00
PNIE Unit Fee:
$0.00
PNIE Permit Fee:
$0.00
F-1
0
Work Without Permit? 0 Yes Q No
$0.00
\.
$0.00
Select allon-Residential
Building or Structure
Q
1BSEL5AffCR
$0.50
Select an Administrative Item
1BCBSC
$1.00
SUBTOTALS:
1 $1.50
$392.00
TOTAL FEE:
1 $393.50
Revised: 1/01/2012
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: loco -30 a
PERMIT # O P t Q
OWNER'S NAME: Ups
PHONE # Ci
GENERAL CONTRACTO p cc✓L
BUSINESS LICENSE #
ADDRESS: ;S'
CITY/ZIPCODE: Kii�t- q G
*Our municipal code requires all businesses working in the city to have a City of Cupertino -business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCON TORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: j
Signature Date
Please check applicable subcontractors and complete the following information:
Y
/ Contractor Signature
Date
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
Y
/ Contractor Signature
Date
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(ci)-cupertino.org
12 CA cx U k
❑ NEW CONSTRUCTION ❑ ADDMON ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESSZ16
&�_
APN # r _ 0
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42,2 W v
OWNER NAME 4Vo2
PHONE6S O- 961-
E-MAII.O'f(IIrTL''S
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STREET ADDRESS
CITY TE, ZIP
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0I�y✓%AJ U i c �j
CONTACT NAME
PHONE
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STREET ADDRESS � Cm'ON STATE,
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT WCONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
eV , 1 vC1 nc{ ,�
LICENSE NUMB
LICENSE TYPE
13
BUS. LIC #
MAIL.
COMPANY NAME E-MAII
F '[ �6 / 3�
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STREET ADDRESS CITY. STATE, ZIP
S
ONE
S
a7h" S :vine ( a k fo
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ARCHITECTIENGINEER NAME J iL
(� YT
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK r
O(ISTING USE
PROPOSED USE
CONSTR. TYPE
# STORIES
USE
TYPE
OCC.
SQ FT.
VALUATION (S)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
-2
Say 6 -
�t
BATHROOM
KITCHEN OTHER
REMODELAREA
REMODEL AREA REMODEL AREA
PORCH ;57
DECK AREA
TOTAL DECKIPORCH AREA
I GARAGE AREA: DETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY []YES
BEING ADDED? []NO
ADDITION? []NO
PRE -APPLICATION [] YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY:
I TOTAL VALUATION:
PLANNING APPL # []NO PLANNING APPROVAL LETTER
EICHLER HOME? IJ NO
/I
OO
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prpperty owner's behalf. I have read this
application and the information I ha a rovided is 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 u ding c tion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agemt Date:�—
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
0--0—VER-THE-COUNTER
'STJ DING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
—Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
C1STAMARD
❑ PUBLIC WORKS
Form if any Hazardous Materials are being used as part of this project
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp 2011.doc revised 06/21/11
'It -
e71