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12080178 CITY OF CUPERTINO 13UILDING PERMIT BUILDING ADDRESS: 21297 PARKWOOD DR CON"I'RACFOR:STEVE PLEVANCIC PERMITN0: 12080178 CONSTRUCTION OWNER'S NAAIF,: AVERY GLENBROOK LP 528 S MA"1'RILDA AVL?STE 2 DATE ISSUED:08/15/2012 O"'NER'SPHONE: 6509618330 SUNNYVAL&CA 94086 PIIOSENO:1408)806-9175 ❑ LICENSED C<lN'I'It.\CI'OR'S nECLARA"I'ION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class_ 1-ic.# r r r Q /�/ � MECH RESIDENTIALCOMMERCIALConlrtctor 9 e' e (RCO O c�-c Data I hereby affirm [hill l and licensed under the provisio sof Cbnpler9 JOB DESCRIPTION: BLDG 37-UNIT 2-DECK REPAIR (coil)mencing is fill Section 7000)of Division 3 of the Business& Professions Code and that nrr license is in full force and effect. hereby affirm under penalty of perjury one of the following tnyo 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.PI Floor Area: Valuation:520000 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 ANN Number:32627037.21297 Occupancy Type: APPLIC\NT CE RTI FICTION I certify(hat 1 have read this application and stile that the above inforination is correct.l agree to comply with all city and county ordinances and state laws relating 13ERNIIT 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 indemniN and keep limitless the City of Cupertino against liabilities,judgments, 180 DADS 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 /yy/� /'' with all non-p In source regi latious per to Cupertino Municipal ode,Section Issued b\�• L 9.18. ) ✓Tjr�1�)�-- SignatureRE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to tiny roofing material being installed If roof is installed without firs(obtaining an inspection,I agree to remove all new materials for hereby affirm chat I am exempt from the Contractor's License Law for one of inspection. [he following two reasons: L as owner of the property,or my employees milh 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&Professions Code) I,as owner of the property,am exclusively contracting with licensed contactors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct[he project(Sec.7044,Business&Professions Code). 1 hereby affirm under penalty of perjury one of[he following three IL\/.ARDOIIS 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 lealth&Safety Coda 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(he Health& performance of the work for which this permit is issued. Safely Code.Section 25532(x)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 theerfornance of the work for which this contaminants as defined by the Buy Area Air Quality Mn nagemen[District I will p maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the permit is issued. Ilealth&Safety Code.Sections 25505,25533,and. 534. I ccrtily that in the performance of due work for which this permit is issued,I shall ^ not ennploy any person in any manner so as to become subject m the Worker's Omn uch.Fh Ci J agent: \ Compensation laws of California. If,alter 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 pemlit shall be deemed revoked CONSI'RIIC`FION LENDING AGENCY I hereby offirm that there is a construction lending agency for the performance of lark's \I'1'LIC\�I'CFRl'IFIC,\"1'10\ for which this permit is issued(Sec.3097,Civ C.) I certify[hit 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 mid state Imus relating to building C0115trUCtlmn,laid hereby authorize representatives ol'thls city to enter Lender's Address upon(he above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCIII•I'FCI"S DECLARATION costs,and expenses which may accrue against said City in consequence of de granting of this permit.Additionally,the applicant understinds and will comply I understand my plans shall be used as public records. with till non-point source regulations per the Cupertino Municipal Code,Sectial 9.18. Licensed Professional Signature Date I CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX(408)777-30,3- building(rJcuoerdno.org . ❑NEW CONST-R••U�CTIO//N��❑ ADD E ALT-.RATION/TI ❑ REVISION/D=-,ED ORIGINAL PER.A'IIT ft PROJECT ADDRESS �.. q QG e }- I AFN B -52-(-f— 21 (D E� OWNER NAME f�vA..--lJ(�JY/��G-L ��a e ' QOO// n PHO NESS O'461—f1 EMAIL S:REE[3 0 a,a s'�• C I-I cru'. o v�y✓l n�v I ,W C A F��`� � ��F�1" z J( CONTACT NAME _ _ q ttAE� Sf(: JL 7 lU�t�GtL PYCJ SS-CSOb` `F1- ES rC•' F �. r� 7 LTJ � acs- ST=ADDRESS 'I-1A QTY,SPATE ZR F - �� ' Ptn e o ❑OWNER ClOWNER-BUU.DER C3 OWNER AGENT [a-CO ,ACTOR ❑CONTRACT OR AGENT ❑ ARCH= ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACIORNAME .V UC1�CA C LICENSE NUMBER J // G� LICENSE TYPE jZ I BUS.LICA COMPANY NAME � ' E�L.J Q U C�lJ I�(G.t I r�CJ MI F STREET ADDRESSr CITY,SCATS,IIP P ONE ARCHIrECr/H4014EER NAME c ) J.n_ GCENSE NUMBER BUS.UC a COMPANY NAME I / Y` I E-MAM FAX STREET ADDRESS CITY.STATE ZIP PHONE DFSCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR.TYPE 9SrORRIES USE I TYPE OCC. SQFC. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET.AREA - BATHROOM MCHE24 OTTD]t REMODELAREA REMODEL AREA REMODEL AREA PORCH AAEA DECXAA&A TOTAL DECIVPORCH AREA GARAGE AAFAU DETACH - ATTACH 0 DWELLING UNM: Is SECOND UNTr ❑YES SECOND STORY ❑YES BEIN'GADDED? []VO ADDITION? FiNO PRE-APPLICATION ❑VES 7 YES,PROVIDE COPY OF LS TBR BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNtNGAPPLY CINO PLANNING APPROVAL LFrrstr EICHLER HOME? C]NO +- Zar OOQ� 87 my signature below,I edify to each of the following: i an?the property owner or authariud agent to act on the prppcty owner's behalf. I have read this application and the inI an I baa to ded is correct. I have read the Description of Work and verify it is accurate. I agree to comply with aU applicable local ordinances and sate laws relating u ding< ,. tion. f authorize representatives of Cupertino to eater tltc above-identified Property for inspection purposes. Signature of Applicant/Agent Date: SUPPLEMENTAL i,`IFORMATiON KEQUIItED Pu.4 CHECK TYPE ROUTING s.e New SFD or MultifaRvly dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDi4G PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW —Commercial Bldgs: Provide a completed Ha�nrdous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Haiardous Materials are being used as part of this project ❑ LARGE ❑ F¢ta uErr _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ N.1SOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ E.4VmON.VUINTAL HEALTH • 31dg4pp_2011.dOc revised 06121111