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12090014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21307 GLEN I'L CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 12090014 CONSTRUCTION OWNER'S NASI E: AVERY GLENBROOK LP 528 S MATIIILDA AVE SfE 2 DATE ISSUED:09/042012 OWNER'S PIPONE: 6509168330 SUNNYVALE.CA 94086 PHONE NO:(408)806.9145 ❑ LICENSED CONTRACTOR'S DECLARATION r 1-1 F7 • BUILDING PERDIIT INFO: BLDG C. ELECT -' PLUMB ' License Class Lie b DIECH r RESIDENTIAL(J CODIAIERCIAL Contractor Ill"Lvlc,� Dale j__ 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APT 1-4-REMOVE AND REPLACEXWINDOWS (commencing with Section 7000)of Division 3 of the Business&Professions (O Code and that my 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 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:520000 I have and will.maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of Ore work for which this permit is issued APN Number:32627036.21307 Occupancy Type: AI'PLICANI'CP:R7'IFICA'1'ION I certify that I have read this application mid state that the above informtion is correct. I agree to comply with all city and county ordinances and state laws relating PERMIT 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 AYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, I8U DAY„ OM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the z granting of this permit. Additionally,the applicant understands and will comply '//}/�/J with all non-p 'nt source regulations per the Cupertino Municipal Code,Section Issue - / Ys C.! Date: 9.18. p/ Signnmr Date_( RE-ROOFS: ❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a 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 two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Done: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALI•ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). hereby affirm under penally of perjury one of the following three IIAZARDOUS NATERIA 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 Health&Safety Code,Sections 25505,'_5533,and 25534. I 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 Ilealth& performance of the work for which this permit is issued. Safety Code,Section 25532(a)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 the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallh&+$afcty Code, etimns 25505,25533,and.553 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 Huth , -age t� J Compensation laws of California. If,after making this certificate of exemption,I ate: !� become subject to the Worker's Compensation provisions of the Labor Code,1 muss forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION[,ENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICA\F CERTIFICATION 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 state 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 liabilities,judgments, ARCI II'1'ECI"S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply 1 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 Iav CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildin cu ertino.o ❑NEW CONSTRUCT ION ❑ ADDITION ❑ RLT=RATION/Ti— 3-3E Sl RED ORIGINAL PERIVET g PROPER ADDRESS c/� /6 I� n,k Ike- -e— n O APNa �(J I _� (�� '�!� OWNER NAME tl / �CG�� /l� `. l- PHONEGSO_O-LJ61_k E-MAIL /{Qlleyt s 1 s0rADDRESS 30 �a A ((s� Iy 0 ffi✓� t *moi CN CONTACT NAME s tC. ✓L 7 [SSC' UAfJCN L P}(Ov tf-TSD b` � •F I 2r% f= ✓ `Q M.'=- ' `Sri STREETADDRESS � 1-1 CITY.YSTATE. ZIP //�� F ❑OwNER ❑ OwNER-BUILDER ❑ OWNERAGENT tU-CO A CrOR ❑CONiRAC;ORAGa'r ❑ ARCTUTBfi ❑ENGINEER ❑ DEVELOPER ❑ TENANT CO1C T OR NAME ` I LICEE NSE NUNM i /� p/ LICENSE TYPE BUS.LIC R COMPANY NAME .E-MAIL F ewe 1 vrP4 S eu c U Ma. STREET ADDRESSCTIY,STATE,ZIP ONE A�' r{ I W ARCH11ECrILNGLNEERNAME , ) .n_ LICENSE NUMBER BUS.UCa COMPANY NAME ,v Yc °-MALL FAX STREET ADDRESS CITY.STATE.IIP /' I I C, PHONE DIPTI FSCRON OF WORK ;✓✓ rj� GcC 'L I(/ r or - U vJ- EXLSDNG USE PROPOSED USE CONSR.TYPE ISTOPIES USE I OCC. I SQFf. VALUATION(5) EXISTG NEW FLOOR DEMO TOTAL _ AREA AREA AREA NETAREA C��(_Jv� BATHROOM KITCH OTHER REMOOELAREA REMODEL ARE REMODEL AREA PORCHAREA DECKAREA TOTALOECMOPORCHAREA GARAGE AREA: U DETACH ' ATTACH MDWELLING UNIT: IS A SECOND UpTr LJ YES SECOND STORY OYES BELNO ADDED? ONO ADDITION'. ONO PRE-APPLICATION OYES tF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION:_ PIANNINGAPPL/ ONO PUNNING APPROVAL LcTIFA EICHLER HOatE? 0N T[L OOCJ+ ay Dry signature below,I certify to each of the following: 1 am the property owner or authorizedagent to act on the prpperty owner's behalf. I have-cad this application and the information I ha a tpvided is correct. I have mad the Description of Work and verify it is accuTam. I agree to comply with all applicable local ordinance and sem laws[elating u ding c ,. tion. f authorize representatives of Cupc,:no to enra the above- en Sed pmpery for mspec 'don purposes. Signature of Applicant/Agmt: �2 SUPPLEMENTAL INFORMATION REQUIRED _ELAN CB'ECKTYPE ROUTING SLE? New SFD or Multifamily dwellings: Apply for demolition permit for �.rttE-cocN.I.Ex Btlu.niNc Pum REVIEW existing building(s). Demolition permit is required prior to issuance of buildi permit for new building. ❑ EXPRESS ❑ PLANNEIG PUN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ s-w my ❑ PUBLIC WORKS forms if any Hazardous Materials are being used as pan of Psis project El LARGE ❑ FrnE nErT Copy of Planning Approval Letter or Meeting with Planting prior to El M,voR 11 SANTTAAY sL'wER Dtsraler submittal of Building Pe, it application. ❑ zrivMON:, NTAL BEAI.TB dfdgApp_2011.doc revised 06/21/11 Building Department City Of•Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U PE RTI N O Fax: 403-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOBADDRESS: PERMIT# OWNER'S NAME: 4 PHONE # loe -6or.- GENERALCONTRACTOFe: BUSINESS LICENSE ADDRESS:] - CITY/ZIPCODE: t -tU iz *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO 13UILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND A L SUBCOi\'TIjA.CI'ORS HAVE OBTAINED A CITY CUPERTI\`O 13USIi\'I:SS LICENSE. � q I am not using any subcon tractors: I/- ` Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum / 'Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date wncr/Contractor 1gnature CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 21307 GLENPLACE DATE: 09/04/2012 REVIEWED BY: Sylvia APN: BP#: 'VALUATION: $20,000 *PERMIT TYPE: Building Permit PLA?4-01EZX\TYPE: Alteration / Repair PRIMARY SFD Or Duplex � ' PENTAMATION 1GENRES USE: PERMIT TYPE: WORK BLDG 38 REMOVE AND REPLACE XWINDOWS SCOPE 11 / Mech. Plan Check Plumb.Plun C'hcck Flec.Plan Check blech. Permit Fee: Plumb. Permit Fee: F.lec. Permit Fee: Other,ihch.Insp. Odrer Plumb Insp. Li I Other Elec.Imp. Plech./lisp.Fec: Plumb. lmy.Fee: Elce.Insp.Fee: NOTE: This esdntate does not include jeer time to other Departments(i.e. Planning Public Works, Fire,Sanitary Server District,School District, etc. . These ees are based on the prelintinarl information available and are only an estimate Contact the Det for addn7 info. FEE ITEMS (Fee Resohaion 11-053 Elf LLLI1/ FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 16 1 # Window/Sliding Glass Door Suppl. PC Fee: (D Reg. Q OTE67 hrs $0.00 $533.00 I111INREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.-0 Reg. Q OTQ•Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Cons•n•uction Tor: Administrative Fee: O Work Without Pennit? O Yes Q No $0.00 E) Advanced Planning Fee: $0.00 Select Non-Residential Q Travel Doctuna Cation FeesBuilding or Structure Strong Motion Fee: IBSBISAIICR $2.00 Select an Administrative Item Bldg Commission Fee:Fee: IBCBSC $1.00 SUBTOTALS: $3.00 $533.001 TOTAL FEE: $536.00 Revised: 07/01/2012