12100060 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21337 GLEN PI, CONTRACTOR:STEVE PLEVANCIC PERMITNO: 12100060
• CONSTRUCTION
OWNER'S NAME: AVERY CONSTRUCTION 528 S MATFI ILDA AVE STE 2 DATE, ISSUED: 101092012
OWNER'S PIIONF,: 6509618330 SUNNYVALE,CA 94086 PHONE NO:(408)806-9145
❑ LICENSED CONTRACI*I'OR'S DECLARATION JOB DESCRIPTION: RF,SIDENTIAL 1,11COMM ERCIA I,
License Class
� Lie.9 /Z S, REMOVE AND REPLACE2,# WINDOWS
Contractor S �-C eVCtr—c_ Date d
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business& Professions
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:$20000
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
AI'N Numhcr:32627036.21337 Occupancy Type:
permit is issued:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (\1'e)agree to save 180 DAY ' OM LAST CALLED INSPEC IO
indemnify and keep harndess the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of die /(� q /.
granting of this permit. Additionally,the applicant understands and will con ply Issued by: �' Date: _/
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Out 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.
❑ O\VNER-RUILDER DECLARATION'
1 hereby affirm that I nm exempt from the Contractor's license haw for one of Signature of Applicant: Dam:
the fallowing two reasons: AL1,ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business d Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to DAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safety Code,Sections 25505,25533,and 25534. I will
hereby affirm under penalty of perjureone of the Following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: Ilealth&Safety Code,Section 25532(x)should 1 store or handle hazardous
I hive and will maintain a Cerifcaie of Conserv to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Ray Area Air Quality Management District
performance of the work for which this permit is issued. will maintain compliance with t e Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the I Iealth&Safety Code,Sect s- 5 55 3,and 25534.
Section 3700 of the Labor Code,for the perfomtance of the work for which this Q /
Owner or authorized agent: / Date:
permit is issued.
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
Compensation laws of California. If,after making this certificate of exemption,I CONSI'RUCI'ION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code;I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this cit'to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the Cit•of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21327 Glen Place DATE: 10/09/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $20,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARYPENTAMATION
USE: SFD or Duplex PERMITTYPE: 1GENRES
WORK Deck Repair 224 sq ft).
SCOPE
Mich.Plan Check Plumb.Plan Check Flee.Plan Check
Mech. Permit Fee: Plumb.Permit Fee: Blec. Permit Fee:
Other bferh.Insp. Other Plumb Insp. Lj Other Flee.1,
dlech. Imp. Fec: Plumb. h"7).Fee: Bler.Insp.Fee:
NOTE: This estinune Anes riot include fees due to other Departments(i.e. Planning, Public Works, Fire,Smtitaq•Sewer District,School
District, etc. . These feav are based on Ute prelhninat3•information available and are onto an estinntle. Contact lite De t or aeldn'I info.
FEE ITEMS (Fee Resolution 11-053h- 71
.a.' __//l U FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00F__271 # Window/Sliding Glass Door
Suppl. PC Fee: (j) Reg. O OT 0.0 hrs $0.00 $666.00 Ili'INREP I Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp..Fee:Q Reg. O OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME_Permit Fee: $0.00
Consn7rction Tax:
Administrative Fee: O
Work Without Permit? O Yes Q No $0.00 E)
Advanced Plannine Fce: $0.00 Select a Non-Residential E)
Travel Docannenunion Fees: Building or Structure O
i
Strong Motion Fee: IBSEISMICR $2.00 Select an Administrative Item
Blde Stds Commission Fee. IBCBSC $1.00
SUBTOTALS: $3.00 $666.00 TOTAL FEE: $669.00
Revised: 10/01/2012
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 n�U
CUPERTINO (408)777-3228-FAX(408)T77-3333• buildina(akuoertino.ora \
❑NEw CONSTRUCIION ❑ ADDTIION ALTERATION/TI ❑ REVISION/DEFEtRID ORIGINAL PERMIT i
PRn L Aon � -eC n APNe
OWNER NAME�Vtn Y �C PHONE O-46t-3rE-0tAR�47/L'K/ s �r Hl4al.
STREET ADOHFCt _ rnv, rE zm /1n FA �6fGr'Fdi= 7(
CONTACT NAME S f C✓L- E-V APJ C.a C- YO k-$'0 6- 1 41 S Tr r ALLL/ G At"--
STREETADDRESS Z;?g'S. MA' y rt"a41 CITY N„ eql(u F —
13 OWNER ❑ OWNEl-VIRDEE ❑ OWNER AGENT w2Wie1CTOR ❑cavraAR9R AGENT ❑ ARcm= ❑ENGIIffER ❑ DEVELoPFR 13 TENANT
CON 1U,CTOHNAMZ e , ' n��G LICENSE NUMB J /6 O� L(CENSETYPEZ5 Bus Dca
COMPANY NAME �-( 1 P 4,a-7-V 1
e4e, v, a &MARS e� eu h?a �rCv
SitiEE7 ADDRRCC �.1CITY.Sl'A'fT;ZIP ONE
6-
ARCH37=IE11GRNEERNAME s 7 LICENSE NUMBER SUS.ECe
COMPANY NAME (� E-MAIL FAX
STREET ADDRESS CITY.STATE,ZIP / PHONE
DESCRIPTION OF WOAK I�'C q I CI 1 r'�PIYG� .S�=rW/ 1// �l W S, -
GIJSE PAOPOSm USE CDNSI0.ME aSTDRnS
USE TYPE OCC SQFT. VALUATION(S)
EXISTG NEWFLOOR DEMO TOTAL
AREA AREA AREA HETAREA
BATBA00lr KITCHEN OOffR
RAfOOELAREA RECODELAREA REMODEL AREA
PORCHARFA DF ARTA -TOTAL DECK?ORCH AAFA riARA!iE ARTA DETACH
ATiwIX
a DWELIDNG UNITS: UYES SRCONDSTORY YES
9P.a'IOADDEDT ❑TA ADDITION ❑NO
PR E-APPLIGTTGN ❑Y6 TYMPROVIRECOPYOF I5THEBLDGAN ❑YPS RE B�cn�nTOTAL VALUATION:_
PtANNwc APPla ❑No rtAnprDNC APrnavALhFrTm cruo ❑No Z 0
dr00 —
By my sign, below,I certify to each of the following I am the property owner or aotherind agent to act on the pipperty owner's behalf. I have read this
application and the information I ha 'ded is cerrecL I have rad the Desciption of Work and verify it is accurate. I agae to muaply with all applicable IDcal
ordinances and state laws relating ding On. I authorize representa Ives of Cupertino to enter the above-identified property for inspection purposes.
Signature ofApplicant/Agent Date: A� 9 • /,;z
SUPPLEMENTAL INFORMATION REQUIRED PrAx�acTYis RODmvc Silt
New SFD or Multifamily dwellings: Apply far demolition permit for ovRaT�eotarra sDDDUNc rtwN aevaw
printing building(s). Demolition permit is required prior m issuanx of building
permit for new building. h ❑ PLANtWG PLAN REVww
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosrae ❑ srA Aan 11Putuacwoaro
form if any Hazardous Mwznals are being used as part of this proj=L ❑ f�R¢ ❑ PmzDzr
Copy of Planning Approval Lerner or Meeting with Planning prior to
submitral of Building Permit application. ❑ MASOR ❑ SANTIARY SEWXR DISTRICT
❑ RNVmoxmxNTAL exA TH.
21dgApp 101 Ldoc revised 06/11/11