12080179 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 21297PAIZKWOOD DR CON'IRACI'OI2:STEVE PL17VANCIC PERMITNO: 12080179
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATIIIIAM AVE 911-E 2 DA'Z'E ISSUED:08/152012
OWNER'S PHONE: 6509618330 SUNNYVALE.CA 94086 PHONEN'O:(408)806-9145
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class 43 Lie.q r r r
AI^ plECll RESIDENTIALCOMMERCIALContractor, C... Dale
hereby affirm that I ant licensed under the provisions of Chapter') JOB DESCRIPTION: BLDG 37-UNITS-DECK REPAIR
(Coil]mencing with Sec(inm7000)of Division 3 of the Business S Professions
Code and than niv license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of die Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft FloorArea: Valuation:$20000
1 have and will maintain Worker's Compensation Insurance,its provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued APN Number:j2627037.21297 Occupancy Type:
AI'1'IJG\N'1'CFai'1'1 F'IC.\'PION 1
I certify that I have read this application and state that the above information is
correct, l agree to comply with all cit•and county ordinances mid stale laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
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, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permil. Additionally,the applicant understands mid will comply
with all non-p t source regu Ali is.per the Cupertino Municipal C e,Se iai Issued by: Date:
9.18.
Signature Date
/,S ly
RF:ROOFS:
❑ OWNER-BUILDEIR 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 nnv materials for
hcrchy afirn that I am exempt from the Contractor's License Law for one of inspection.
the following Iwo reasons;
I,as owner of the properly,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business g Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to At.[,ROOF COVERINGS TO BE CLASS"A"OR BE'I-I'ER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penally of perjury tine of the following three IL\%ARDOUS 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 I Ieallh&Safetv 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 dlunicipal Code.Chapter 9.12 and the Health S
performance of the work for which this permit is issued. Safely Code.Section 2.5532(4)should I 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 taw work for which this contaminants its defined by the Bay Area Air Qmdit•pinnugement District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.1_and the
Ilealth S Safety Code.Sections 25505,25533,and 25534.
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 Owner n horn a u:
Compensation laws ofCalifomia. If,after making this certificate of exemption,I - Date:
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 CONSTRUC7110N LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICA\I'CERTI FIC TION 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 stale laws relating
to building construction,and hereby authorize representatives of this city to enter I-ender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify land keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the .\RCI I1'I'IiCI"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,Section
9.18. Licensed Professional
Signature Date
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 050143255
Ty 7�3 • r )777-36ailCdi7n_o(c�cuper5no.org
CUPERTINO
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❑NEW CONSTRUCil ❑ ADDITON ALT-RATION./TI ❑ REVISION/DEFERRED ORIGINAL PER11117M
PROSECT ADDRESS y� l/ / / rS^^QL'� 3 AFN 1 a 7- 0 3
OWNER NAIL i / 'J / PHONEFS O- 961—k E-MAM AVNYL`fS
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CONTACT NAME S I L ✓L � �C' L/Af1C-1 C_ PyoO ts-tSa t' c.,7 `�I` ES 7'N t= LCL/
SIREc ADDRESS 41 CTT'(,STATEIIP F
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❑ OWNER ❑ OWNER-BURDER ❑ OWNER AGENT 1YCpN RAC 0R ❑CONTRA=0R AGENr ❑ ARCRTTECr ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAMEe V /(2 uG1 nGcLICENSE NUMB LICENSE ME BUS.LIC0
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CM0ANY NAME E-MAIL F
STREET ADDRESSS
CRY.STATE t.7 P ONE
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ARCHSrECr/ENOMEM NAME E ) .n_ LICENSE NUMBER BUS.LICK
COMPANY NAME 1� Yc I EMAIL FAX
STREET ADDRESS /� CTS.SLATE,IIP y( �7 PHONE
DFSCRt ON OF WORK ' - t' \ 7 g
EXISTING USE PROPOSED USE CCNSTt PE YSIORIES
USE TYPE OCC SQ-FT. VALUATION(S)
E=G NEW FLOOR DEMO TOTAL
AREA AREA AREA NET.ARFA
BATHROOM KtrCHEN OTHER
REMODE.AREA Rc-MOOELAREA REMODEL AREA
PoRCH AREA DECK AREA TOTAL DECR/PORCH A0.EA GARAGE AREA DETACH
ATTACH
ppWELL'NG VNr15: IS A SECOND UNIT ❑YES SECONDSroRY ❑YES
8ELNG ADDED? E]NO ADDTTON? ANO
PRE-APPLICATION ❑vEs 7YES,PROVIDECOPYOF IS TBE BLDG AN 11 YES RECEIVED BY: TOTAL VALUATION:_
PIANNNG APPLI []NO PLANNING APPROVAI.ITER EICBLER SOME? [jNO Zd/0OC- -
1 By my signature below,I cerdfy m each of the following: I am the property owner or authorized agent to act on the prgperty owner's behalf. I have read this
application and the information I ha a rovided is correct. 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 c tion. I aurhorze representatives of Cup er i.o to enter the above-ideatifed property for Gtspettion pmposeS.
Signavzt of AppEcant/Agent Date:
SUPPLEMENTAL IN FORMATION REQTIaED PIAN CHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for11OVER-THE-COUNTER ❑ BDa.Dute PUN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLAN:,'Ivc PUN REvirw
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ SrANVARD ❑ PI-BLICwORM
form if any Hazardous Materials are being Used as pan of Iris p;ojecf L4R❑ GE ❑ Fina HEer
Copy of Planning Approval Letter or Meeting with Planning prior to
suhmiral of Building Permit application. 11 M UOR ❑ SANITARY SEWER DLSTR1Cr
❑ EN'VIROXNEENTAL HEALTH
dldgApp_201 Ldoc revised 06/21/11