12040026CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10193 PARKWOOD DR
CONTRACTOR: STEVE PLEVANCIC
PERMIT NO: 12040026
CONSTRUCTION
OWNER'S NAAIE: AVERY GLENBROOK LP
528 S hIATHILDA AVE STE 2
DATE ISSUED: 04/05/2012
OWNER'S PHONE: 6509618330
SUNNYVALE. CA 94086
PHONE NO: (408) 806.9145
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class 9 r W Lie. N
r r r
jr
MECH RESIDENTIAL COMMERCIAL
Contractor, Ft'Aze' � 6 /a9 c e. L. Date s /
I hereby affirm that 1 am licensed under the provisions of Chapter
JOB DESCRIPTION: REMOVE AND REPLACE 36 WINDOWS
(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 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
Sq. Ft Floor Area:
Valuation: $20000
performance of the work for which this permit is issued.
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. 10 193
Occupancy Type:
APPLICANT CERTIFICATION
I certify (hal I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and stale 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 ofCupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION,
costs, and expenses which may acme against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulate c the Cupertino Municipal Code, Section
�%{1 '
Issued by: z5yp L
/J%Date: T
9.18.
i
Signature Date
RE -ROOFS:
❑ OWNER -BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material beitg installed If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
Signature of AppliuhnC Date:
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044. Business & Professions Code).
1 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, 2.5533, and 25514. 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(m) should 1 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 Ouality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safely Code, Sections 25505, 25533, and 25534.
f 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
Owner aut ize agent:
Compensation laws of California. If, after making this certificate of exemption,)
Date:
become subject to (he Worker's Compensation provisions of the Labor Code, 1 mus(
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that (here 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 stale that the above information is
Lender's Name
correct. 1 agree to comply with all city and county ordinances and stale laws relating
to building construction, and hereby outhorize representatives of this city to enter
Lender's Address
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against Iiabilities,judgments,
ARCHITECT'S ITF.(T'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
granting 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 Dale
CUPERTINO
CONSTRUCTIONPERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777.3228 • FAX (408) 7/77-3333 • buildinct( cuoertino.G
❑ NEW CONSTRUCTION ❑ ADDMON LI ALTERATION / TI ❑ REVISION / DEFM=
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#DWELLING UMTS:
1SASZCOKDUKZT QYES
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PRE -APPLICATION OYES 7YES PROVIDE COPY OF.
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By my signature below, I certify to each of the fbUawmg.. I am the property owner m authariEed agent to act on the ptpperty owae>'s behalf i have read this
application mad the information I bevided is correct I have read the Descriptiaa of Work and verify it is accurate. I agree m comply with all applicable local
ordinances and state laws relating 29 1 1 amborin representatives of Cupertino to toter the above- i ti8ed property for inspection purposes.
Signs= ofApplican/Agent Data: — _ 2
SUPPLZV=AL INFORMATION REQUMD
PLAN CHLCXTYrE
ROVMG W TIP
H-0-�-M-THEroDNTER
LTBDnDvtG FLAK REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ mcratass
❑ PLANIONG PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
11PUBLIC WORIM
Form. if any Hazardous Materials are being used as part of this project
❑
❑
TARGE
PmE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ nwGR
❑ SANITARY SEWER DISTRPR
submittal of Building Permit application.
❑ ENVMONASNTALHEALTH
BldgApp_1011.doc revised 06121111
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