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12050176CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10175 PARKWOOD DR CONTRACTOR: STEVE PLEVANCIC PERMIT NO: 12050176 CONSTRUCTION OWNER'S NANIE: AVERY OLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED: 05/23/2012 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 % �/_ 3 Lic.4 '� Z e —. r r r /+// {/qq�, MECH RESIDENTIAL COMMERCIAL Contractor\, +ate' vUCyf�r� Date : -S74:73 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: BLDG 33 - R17MOVI: AND REPLACE (28) WINDOWS (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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 orthe Labor Cade, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and slate 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 -po' source r; orations per the Cupertino Municipal Cade, Section 9.18. A Signature : -.Date ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the strucmrc 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penally of perjury one of the following three 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. I certify that in the perf unnance 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 Compensation laws ofCalifamia. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must fonhwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 1 certify that 1 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 regulations per the Cupertino Municipal Code, Section 9,18. Date Sq. FI Floor Area: I Valuslion: $20000 APN Number: 32627037.10175 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by:. /;29/1 LAZ�r-rl Date:--1r-g,3 -Ig Rh: 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 remove all new materials for inspection. Signature of Applicant- Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air 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 Health &Safety__1 ions25505, 2553},and 25534, Ow C 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 3 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32627037.10175 DATE ISSUED.......: 05/23/2012 RECEIPT #.........: BS000016889 REFERENCE ID # ... 12050176 SITE ADDRESS .....: 10175 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 SAL ---------- ------------- ---------- -------------------- 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 CARD 1,243.50 VISA --------------- TOTAL RECEIPT 1,243..50 CUPERTINO n NEw CONSTRi1CrlON CONSTRUCTION PERMIT APPLICATION 2,C) COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING_ DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) T77-3333 - buildina(Zi)cuoettino.orD F1 A 7 DDMON I I ALTERATION/71 M REVISION/DFFERRFD nRTCTWAI-PFanmre PROTECTADDRESS +-J 33 - AFFNLL0 - 2-7 - 0 5-7,, 0 a ` 1 - OWNEANAME ago, PHONEV SvcnYG E MALL /S /. STREETADDRESS CI1Y. TEZ%n, vAI F I e CONTACT NAMEP _ ✓L_ 7 FuAtJGRC c— -fcd ONE t7fs $ob- 741\^Me- STREET ADDRESSS. II CITY, S A F F V'd e N U IJ ❑ OWNER ❑ OWNER-SUB.DER ❑ OWNER AGENT 5-MITAACTOR ❑ CONTRACTORAGENr ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNA'a ' LICENSE NUM�-r0 B 1%/ <7(4 ( LICENSE TYPE j2 Bus.LIC 9 el.l Vc r -"C- ` / �J E-MA COMPANYNAME E-MAIL{ F e e S e�pjCv h7a, ,Cvm STREET ADDRESS SPATE, IIP a S�� vuleL v ONE 6- S ARLiDTECTIENGAIEERNAME C ) LIGENSENUMBER BUS. LICp COMPANY NAME E-MAIL FAX STREET ADDRESS CITY SSSTTATE,ffi PHONE DESCRIPTIONDESCRON OF WORK (� l /7 Ve CU �e /S /a, C e- _ / W U . / uOf G USE PROPOSED USE CONSTA. E I Y51aRRLL5 z USE TYPE OCC SOFT. VALUgTION <!� E "'.9wV/ (5) EYSTG NEW FLOOR DEMO TOTAL AREA AREA AAAA NET.AREA _ BATHROOM RTTCHEN OTHER REMODELAREA RENIODELAREA REMODELAREA PORCH AREA DEl]CAAF.A TOTAL DECWPoACH GEARFA DETACH H ATTACH N DWELLWG UNDS: CONDUNTT ❑YES SECONDSTORY YES BEING ADDED? ❑NO ADDIf10M. ❑NO PiLEAPPLICAiP ❑YES IFMPROVmEcOPYoF IS THE 3UG AN ❑YES RECEIVED Y: TOTAL VALUATION: PLANNINGAPPLY NO PLANNING APPROVAL LETTER. EICHLER HOME? ❑NO r13 __ / zdr OOCJ: By my sigean?re below, I certify to each of the following: I am the property owner or authorized agent to act on the prpperty awner'? behalf. I have read this application and the infam . 011 I he a vided is correct I have read the Description of Work and verify it is accurate. I agee to comply with all applicable local ordinances and state laws relatin ding c don. I authorize representatives of Cupertino to enter the above-id`entified property for inspection purposes. Date: ' g3 -/ C�1- Signature ofApplicandpgent J SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROOTING SLIP New SFD or Multifamily dwellings: Apply far demolition permit for ❑ existing building(s). Demolition permit is required prior to issuance of building OVER-THRCO@RER BUILDiNG PIAN REVIEW permit for new building. ❑ MR= ❑ PLANNING PIAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project ❑ LARGE ❑ ETRE aEPT Copy of Planning Approval Letter or Meeting with Planning prior to _ submittal of Building Permit application. ❑ MAtoR ❑ SANITARY SEWER DISTRICT ❑ ENYmON.VIXNTAL HEALTH 81dgApp_2011.doc revised 06/21/11