12040071CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:. 10193 PARKWOOD DR
CONTRACTOR: STEVE PLEVANCIC
PERMIT NO: 12040071
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP
528 S MATIIILDA AVE STE 2
DATE ISSUED: 04/12/2012
OWNER'S PHONE: 6509618330
SUNNYVALE. CA 94086
PHONE NO: (408) 806-9145
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT
License Class Lic. q !
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MECH RESIDENTIAL COMMERCIAL
Contractor l'e(h<<n...^-` Date
1 hereby affirm that l em licensed under the provisions of Chapter 9
JOB DESCRIPTION: APT 10- REPLACE/REPAIR 2 DECKS (PICKETS,POSTS)
(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. FI Floor Area:
Valuation: $5000
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
pennit is issued_
APN Number: 32627037.10193
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 slate 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,
]gQ DAYSrF M 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
int
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with all non -p source re nP4tlons per the Cupertino Municipal Code, Section
Issue b ' �i �� Date:
9.18.
`�
Signature - Date - //
RF" -ROOFS:
❑ OWNER -BUILDER DECLARATION
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 remove all new materials for
1 hereby affirm that I 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 . "I.c nt: 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 Chapler6.95 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. 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 I 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
Heallh Safety C de: Sections 25505, 2553zx
1 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
Own ul ized gent:
Compensation laws of Cali forma. If, after making this certificate of exemption, I
Dale: �
become subject to the Worker's Compensation provisions of the Labor Code, 1 muss
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. 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
Lender's Address
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
ARCHITECT'S DECLARATION
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, Seclim
9.18.
Licensed Professional
Signature Dale
3. ITEMS OF 9
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32627037.10193
DATE ISSUED.......: 04/12/2012
RECEIPT #.........: BS000016531
REFERENCE ID # ...: 12040071
SITE ADDRESS .....: 10193 PARKWOOD DR
SUBDIVISION ......:
CITY ..............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
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
1DECKWOOD
EACH 1.00
457.00 0.00 457.00
0.00
TOTAL PERMIT
---------- ---------- ----------
458.50 0.00 458.50
----------
0.00
CUPERTINO I
❑ NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) T77-3333 • buildinG(")m cuoerdno.orn
❑ ADDITION ❑ ALTERATION/TT ❑ REVISION/r)FFFRRM nRtnMAI RVR%. w
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DESCRIPTION OF WORK
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ENISTLNG USE
PROPOSED USE
CONSTILTYPE
YSIVRfES
USE
TYPE
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SQFT.
VALUATION (S)
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AREA
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BATHROOM ICITCH:N OTHER
REMODEL. AREA REMODEL AREA - REMODEL AREA
PORCHARL+A DECKAREA TOTAL DECWPORCH AREA GARAGE AREA: DETACH
ATTACH
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is A SECOND UNIT UYES
5ECO1V) STORY UYES
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PRE -APPLICATION ❑YEs IF YES,, PROVIDE COPY OP
PLANNDIGAPPL9 QNO PLANNING APPROVAL LETTflI
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RECEIVFDBY:
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TOTAL VALUATION:
BY my signature: below, I certify to each of the follawmg: I am the property owner or authorized agent to act on the prfperty owner's behalf. I have read rids
application and the information 1 ha a vided is cornett 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws mlating ding don. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicanotAgmo N Daze:
SUPPLEME'NT'AL INFORMATION REQUIRED
PLAN CHECK LYPE
ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for
❑ ovEn-TlSz comrrEx
❑
existing building(s). Demolition permit is requited prior to issuance of building
nunmi aG PLAN Revurw
permit for new building.
❑
❑
EXPRESS
PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ srArinmw
❑
form if any Hazardous Materials are being used as part of this project
PUBLIC WORJL-
❑ LARGE
❑ PINE bzrr
_ Copy of Planning Approval Letter or Meeting with Planning prior to
'
submittal of Building Permit application.
❑ MAIOR
❑ SANITARY SEWER ULSCRICr
❑ ENVERON.YENTAL BEAT TH
B1dMpp_?0l Ldoc revised 06/21/11
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