12040070CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10193 PARKWOOD DR
CONTRACTOR: STEVE PLEVANCIC
PERMIT NO: 12040070
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP
528 S NIATHILDA AVE STE 2
DATE ISSUED: 04/12/2012
OWNER'S PIIONE: 6509618330
SUNNVVALE, CA 94086
PHONE NO: (408) 8069145
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License ClassLic. p
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MECH RESIDENTIAL COMMERCIAL
Curumclorl!4 ({//Q�,kUkC�,— Date
hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: APT 2 - REPLACEIREPAIR 2 DECKS(PICKETS,POST,BEAM)
(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 cenificate 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: $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
APN Number: 32627037.10193
Occupancy Type:
permit is issued. A^
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 ISNOT 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 1�0 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against l iabililies,judgments,
18O D2AYLAST 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-p t source regulmims per the Cupertino Municipal4odeSccuor
if0 Date:
SignatureDate
RF.-ROOFS:
❑ OWNER-BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed. Ira roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of
inspection.
the following Iwo reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Dmc:
will do the work, mid 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 herebyaffirm under penally of perjury one of the following three
IIA'/•ARDOUS MATERIALS DISCLOSURE
declarations:
1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consenl 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 Cade, 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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Ilealth Safely Code, Sections 25505, 25533, and 25534.
I cenify 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
Ow iz agent: 1
Compensation laws of Cal ifomia. If, after making this certificate ofcxemption,l
Dale: d'
become 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 AGENC\'
1 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 slate that the above information is
Lender's Name
correct. I agree to comply with all city and county ordinances and stale 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
indemnify and keep harmless the City of Cupertino against l iabil ities. judgments,
and expenses which may accrue against said City in consequence of the
ARCHITECT'S DECLARATIONcosts,
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
CCUPERTINO
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CONSTRUCTION'PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO. CA 95014-3255
(408) 7T7-3228 • FAX (408) 777-3333 • buildinO(��cuoertinc.oro
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DESCRIPTION OF WORK�J%//1
EXISTING USE
PROPOSED USE
CONSTILTYPE
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TYPE
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SQ.FT.
VALUATION (5)
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NEW FLOOR
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TOTAL
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BATHROOM IQTCNEN OTHER,
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TOTAL OEmVPORIX AREA GGEARAAREA: DETACH
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#DWELLING UNITS:
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PRE-APPLICATION ❑YES IF YES, PROVIDE COPY OF
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TOTAL VALUATION:
PCANNINGAPPLB ❑NO PLANNING APPROVAL LEITER
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By my signature below, [ certify to each of the following. I am the property Owner of authorized agent to act on the Merry owner's behalf. 1 have read this
application and the information I ha 'dcd is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating ding c tion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent Dare:
SUPPLEVffi-N'ALiNFORMAT[ONREQUIRED -
PLANCHELxTYrs
ROUTING ST
New SFD or Multifamily dwellings: Apply for demolition permit for
❑ OVER-THE-CoDNTER
❑
existing building(s). Demolition permit is required prior to issuance of building
BUILDiNG PLAN REVIEW
permit for new building.
❑ EXPRESS
❑ PLAXMG PLAN REVIEW
--Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORIO
Tom if any Hazardous Materials are being used as part of this pmjecL
Cl LARGE
❑ FIRE DET
Copy of Planning Approval Letter or Meeting with Planning prior to
_
of Building Permit application.
❑ MAIOR
❑ sANrrARY SEWER DISTRICT
❑ ENVIRONMENTAL BYAT.TH
31dg,4pp_201 Ldoc revised 06121177
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