12100061 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRF,SS: 21337 GLEN III, CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 12100061
CONSTRUCTION
OWNER'S NAME: AVERY CONSTRUCTION 528 S MATHILDA AVE STE 2 HATE ISSUED: 10/092012
OWNER'S PHONE: 6509618330 SUNNYVALE,CA 94086 PHONE NO:(408)806-9145
❑ LICENSEn CON TRACT'OR'S DECLARATION JOR DESCRIPTION: RESIDENTIAL COMMERCIAL[]
License ClassLie.N Y� APT 2- DECK REPAIR
Contractor��, PIP,UGt,'W �- Date d
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business S Professions
Code and that mr 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[his permit is issued. Sq.Ft Floor Area: Valuation:$5000
I have andevill maintain Worker's Compensation Insurance,as provided for by
.Section 3700 of the Labor Cade,for die performance of the work for which this
\I'\Number:32627036.21337 Occupancy Type:
permit is issued.
APPLICANI'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 80 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. (We)agree to save 180 DA �S OM LAST CALLED INSPEC�'ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, /a
costs,and expenses which may accrue against said City in consequence of the
�(� CI /
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code Section
9.18.
�• RP,ROOFS:
Signature Date V 4 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without fust obtaining an inspection,1 agree to remove all new materials for
inspection.'
❑ OWNER-BUILDER DECLARATION
1 hereby affirm that 1 nm exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL 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&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to BAZARDOIIS MATE RIAI S DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ileallh&Safety Code,Sections 25505,25533,and 25534. 1 will
hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: I Ieakh&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I 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 Bay Area Air Quality Management District
performance of the work lot which this permit is issued. _ will maintain compliance with the erttno Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code.Section - 50 53 ,and 25534.
Section 3700 of the Labor Code,for die performance of die work for which this 4
Owner or authorize)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 Cali foruia. If,after making this certificate of exemption,I CONSTRUC`FION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 mus[ 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, work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
AI'PLIC,\N'I'CER'1'IFICA"PION Lender'sAddress
I certify that I have read this application and state that the above information is
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
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCIl FFECI"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
�133� FEE ESTIMATOR — BUILDING DIVISION
1:21 ADDRESS:441fGlen Place DATE: 10/09/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD Or Duplex PENTAMATION 1GENRES
USE: PERDIIT TYPE:
YORK Deck Repair 224 sq ft).
SCOPE
Nech. Plan Check Plumb.Plau Check Elec.Plan Check
,Neth.Permit Pee: Plumb. Permit Fee: Flee. Permit Pee:
Other.Nech. Insp. Other Plumb Insp. Ll I Other Elce.Imp.
,Neth.1tup.Fee: Plumb. hmp.Fee: Elco Insp.Fee:
NOTE: This estimate sloes not include jeer cure to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelitninan information asmilable and are onh,an estimate. Contact the De t or acichr'I info.
FEE ITEMS (Fee Resolution 11-0>3 Ly- 7/1/ll) FEE F$467.001
EE MISC ITEMS
Plan Check Fee: $0.00 # Deck/Deck Railing
Suppl. PC Fee: Q Reg. O OT 0.0 hrs $0.00 1DECKtVOOD Deck (wood)
PME Plan Check: $0.00
Permit Fee: $0.00
Supp]. Insp. Fee Q,Reg. Q OTFO-0-1hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative Fee: O
Work Without Permit? Yes Q No $0.00 E)
Advanced Plannine Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fees: Building or Structure 0
i
Strove Motion Fee: I BSEISMICR $0.50 Select an Administrative Item
Bide Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $1.50 $467.001 TOTAL FEE: $468.50
Revised: 10/01/2012
CONSTRUCTION PERMIT APPLICATION „` n� B
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 0
10300 TORRE AVENUE a CUPERTINO,CA 95014-3255 �1
CUPERTINO (408)777-3228•FAX(408)777-3333•buildinafacuoerlino.orD 1
❑NEW CONSTRUCTION ❑ ADDITION TERATION/Tl ❑ REVISION/DPFERRSD ORIGINAL PERMIT C
Faozi3� C 4 2 AFN0 L52-(A 7.'( 03(—p
OWNER NAME AV&72Y G•C�'IJ�Q�/� ` /- FHONE6S-O-961-a- E44AB.AVLrn ys HL.fCal.
STREET ADDRFtt �. CITY• TE ZIP n
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MWACT NAME S�L ✓C .� FU ArJ GRL F`l0 ff-fS06-
STREET ADDRESS �—_ it CITY.SFA N e U F
❑OWNER ❑ OWNER-BllRDER ❑IOWNEAAGINT IIYCOM//RACTOR ❑LVMRACTORADFNT ElARcm= 13 ENGINEER ❑ oveoFF]t 11 TENANT
CANTRACTORNAMFME ,V 1 ✓TCR C LICENSE NUMB I�-/6 O� LICENSE TYPE j2 BUS.LICE
COANYNAME 6MAM / 1 (� E
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SnlEE7 ADDRESS CIrv,
STATE,ZT ONE
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ARC7DTECT/ENrI NmLNAw- a 7 LICENSE NUMER BUS.UC a
COMPANYNAME E-MAIL FAX
STREET ADDRESS QTY.STATE ZIP PHONE
DESCRIPTION OF WORK
GUSE PROPOSED USE CONSnR-TYP6 •SIORO5
MC rt USE TYPE OCG SQFF. VALUATION(5)
AN
EXISTT NEW FIDOIR✓ DEMO TOTAL
AREA AREA AREA NET.AREA
BATHROOM KITCHEN OTHER
RFMODELAREA REMODELAAEA REMODEL AREA
PORCH ARCA DFS]CARFA TOTAL DECIVP�R�[AR&T GARAGE AREA DETACH
Lr/ ATFACH
/DWELLING LINOS: 6ASECOND UNIT YES SECOND STORY YES
BEING ADD®? ❑NO ADprrtOM [I]NO r.
PRE.APP 71014 ❑YES T YES.PROVIDE COPY OF ISTBRBI.DGAN ❑YES RECEIVED BY• JWAL VALUATION:_
PLANNDIGAPDL' ONO PLANNING APPROVAL LETTER vctflARso0 ❑NO
13Y Dry signature below,I certify to each of die following I am the property owner car authored agent to as can the prgpery owner's behalf—I_have r=dthis
application and the information 1 v dcd is correct. I have tend the Description of Work and verify it is accma a I agree to comply with all applicable local
ord nia ces and state laws relating dng Toa I archon=reptaenativa of Caperton to eater the above-identi5ed propperty for iaspectim proposes.
Signature ofApphaatfAgent Dare: 7 '
SUPPLII.gNTAL INFORMATION REQUIRED PLAN=- (1KTyFK ROOTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for �Q ovF THErOGPrreB NUanirG PIAN aevIEw
existing building(s). Demolition permit is requimd prior tD isstrance of building / \
permit for new building. ❑ EalaEs PLANNING PLAN REVIEW
Coffiercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sTANo, R ❑ P Lsc woana
form if any Hazardous Materials are being used m part of this projxL
❑ IASd ❑ Flawir'pr
Copy of Planning Approval Letter or Meeting with Planning prior to El M,LIoa ❑ sANrrARY NEWER otslRicr
submittal of Building Permit application.
7.NVI80MaKTAL ay.r TH
•dldgApp 2011.doc revised 06/31/11