12080173 CITY OF CUPERTINO BUILDING PERMIT
BUILDINC ADDRIiSS: 10145 PARKWOOD DR CON FRACFOR:STEVE PLEVANCIC PERMITNO: 12080173
CONSTRUCTION
OWNER'S NANI E: AVERY GLENBROOK 1-P 528 SMATIDLIIAAVF-SE2 DA'Z'E ISSUED:08/152012
OAVNE,R'S PHONE: 6509618330 SUNNYVALE,CA 94086 19[ONE NO:(40a)806-9145
❑ LICENSEID COYIRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB F_
License Class Lie.N
MECIi r RESIDENTIAL r COMMERCIAL r
Contractor-6 i2jkA,1 Date
lurch,v of iron that I am licensed under the proyisiuns of Chapter 9 JOB DESCRIP'T'ION:BLDG 36-UNIT 4-DECK REPAIR(136 SQFF)
(commencing with Section 7000)of Division 3 of the Business S Professions
Code and that nn'license is in full force:and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self insure lot Worker's
Compensation,as provided lot by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued Sq.Ft Fluor 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
permit is issued. APN Number:32627037.00 Occupancy Type:
A PPLICAN1'CERTI FICATION
I certify that I have read this application mid state that the abocc information is
correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK ISNOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned propeny for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indeninify and keep harmless[lie City ofCupertino against liabilities,judgments, 180 DAYS FROM 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
with all non-p t source egulalinms per the Cupertino Municipal ode,S•ctnon Issued by: Date: - --�'/'L-
9.18.
Signator Uatc
RE ROOFS:
❑ OWNER-Bll I LDER DECLARA'T'ION 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 inn exempt from the Contractor's License Lawfor one of inspection.
the following two reasons:
I,as owner of the property,or my enmployces with wages as their sole compensation, Signature of Applic nt: Date:
will do the work,aid the stmeture is not intended or of leredfor sale(Sec.7044,
Business S Professions Code)
I,as owner of the property,am exclusk ely contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BE'17ER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three HAZARDOUS NIATERIAI S 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 I Iealth&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 I Iculth S
performance of the work for which this permit is issued Safety Code,Section 25532(a)should I core 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 Ilay Arca Air Quality Management District 1 will
permit is issued: maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Ilculth S Safety Code,Sections 25505,_5533,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 Own r a uriieJ ager:
Compensation laws of California, If,after making this certificate of exemption,I ( Date:
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked CONSI'RUC1'ION LENDING AGENCY
I hereby alirm 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 dial the above information is Leader's Name
correct. I agree to comply with all city and county ordinances mid state Imus 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 andkeep harmless the City ol'Cupertino against liabilities,judgments, ,ARCA I'I'FCI"S I1FCL.AR.V1'ION
costs,and ecpenses which may accrue against said City in consequence of[lie
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 Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10145 Parkwood DATE: 0811512012 REVIEWED BY: Sean
7m- 4 APN: BP#: 'VALUATION: 1$5,000
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY Buildina is PENTANIATION
Multi-FamilyDwelling 1GENRES
USE: >3 Stories O Yes (D No PERM19'Tl'PE: A
WORK Deck Repair 136 sq ft to Building 36 Unit 4.
SCOPE
Meet. Plan Check Plumb.Plan Check Flee.Plan Check
,Lice/,.Permit Fee: Plumb.Permit ree: Clec. Permit ree:
Other,mlech.Imp, Plumb Invp. Onp.
Other Cler.l
klech.bray.rec: Plumb. h,sp. ree: rice.Insp.rec:
NOTE: This estinmte does not include jeev Clue to other Departments(i.e. Planning, Public Warks, rire,Sanitary Sewer District,Schaal
District.etc.). These eev are ha.ved on the preliminarl information available and are only an estimate. Contact the Dept for aild n'I info.
FEE ITEMS (Fee Kesohaion /1-053 F_B: 7/1/11) FEE QTY/FEE I MISC ITEMS
Plan Check Fee: $0.00 1 # Deck/Deck Railing
Suppl. PC Fee: Q Reg. O OT 0.0 -its-
$0.00 $467.00 IDCCKII100D Deck(wood)
PME Plan Check: $0.00
Permit Fee: $0.00
SuppI. Insp. Feel@ Reg. OOT p.p hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tar:
Administrative Fee: O
Work Without Permit? O Yes Q) No $0.00 0
Advanced Plannine Fce: $0.00 Select a Non-Residential E)
Travel Documentation Fees: Building or Structure O
Strong Motion Fee: IBSFISMICR $0.50 Select an Administrative Item
Bldg StdsCommission Fee: ICCBSC $1.00
SUBTOTALS: $1.50 $467.00 TOTAL FEE: $468.50
Revised: 0 7/0112 01 2
CONSTRUCTION PERMIT APPLICATION f 70
l
EllCOMMUNITY DEVELOPMENT DEPARTMENT r BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 • FAX(408)777-3333 • building0cuoerdno.oro
❑NEW CONSTRUCT ION ❑ ADDMON
AALTERATI N/TI vEl✓lnREVISION/�Da-VEi/Z� ORIGINAL PERMI
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PROJECT ADDRESS OLIS FN44 2-2O�
OWNERNAME /qVLi / / L nHOVO- T61—f E-MAIL
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CONTACT NAME
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STREET ADDRESS S. Oe 1-1 CTTY,STATE. IIP
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❑OWNER ❑ OWNER-BUS-DER ❑ OWNER AGENT LIYCONTRACrOR ❑CONiI ACTOR AGENT ❑ ARC=C7r ❑ENGINEER ❑ DEVELOPER ❑ TENANT
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CONTRACT ORNAME LICENSE NIM1IB I {/ /yh L[CENs'c TYPE/{�� HUS.LiCM
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ARCPUT'ECT/ENGLNEERNAME t ) .A_ LICENSE NUMHER HUS.LIC0
COMPANY NAME ` I E-MAIL FAX
STREET ADDRESS I CITY.STATE,ZIP PHONE
DESCRIF ION OF WORK 1 -
�ryvG USE PAOPOS'e,D USE CONS TYPE y SrORS
Jlql- `y'.EUSE TYPE OCC. SQ}T. VALUATIONS)
E G NEWFLOOR DEMO TOTAL
AREA AREA AREA NET.AREA
BATHROOM KITCHEN OTiffR
REMODEL AREA REMODEL AREA REMODEL AREA
PORCHAREA DECKAREA TOTALDECI(PORCHAREA GARAGEAREI. DETACH
❑ATTACH
;I DWELL WG UNUS! iRAS-Cc
NO U�Tr YES SECON-D STORY ❑YES
=SIADDED? ❑NO ADDrrtON? []NO �y-�-•��
PRE-APPLICATION OYES T YES,PROVIDE COPY OF I ts=BLDGAN ❑YES RECEIVED H TOTAL VALUATION:_J
PIANNP•GAPPLY []NO PLANNL"IG APPROVAL LETTER UCELER HOME? ANO ^� _
By my signature below,I edify to each of the following: 1 am the property owner or authorized agent to act ontheprypery owner's behalf I have read this
application and the information I he a rovided is corm, CL I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and sate laws relating' u ding a .. tion. I authorize representatives of Cupc=uo to=a the above-iidmti5ed prope;y for inspection purposes.
Signature of Applicanr/Ageut Date: y
SUPPLEMENTAL INFOKMATIONREQUMED PIAN CHECK TYPE ROVIViGSLB
New SFD or Mulifatmly dwellings: Apply for demolition permit for `RI' OVXR-THE COM=RHUI DiNG PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building J"`
p=it for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ srAnDARD ❑ PUHLIc w0sm
I=if any Hazardous Materials are being used as part of this project. ❑ LARc ❑ Fmz b=
Copy of Planning'Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Pe it application. -
❑ E.YVDiONNMXTALREALTH
•NdgApp_2011.doc revised 06/21/11