12100058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21327 GLEN PL CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 12100058
CONSTRUCTION
OWNER'S NAME: AVERY CONSTRUCTION 528 S MATIIILDA AVE STE 2 DATE ISSUED: 10/092012
OWNER'S PHONE: 6509618330 SUNNYVALE,CA 94086 PHONE,NOo(408)806-9145
❑ LICMNSEDCO\1'RACI'OR'SDF.CLARA'1'ION dOBDESCRIPTTON: RESIDENTIAL COMMERCIAL.
License Class b Lic.# APT 6- DECK REPAIR
Contractor act-f_&Lrbwal,C Date 10_1q11J__
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
.(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that are license is in full force and effect.
1 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:$5000
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
APN Number.32627036.21327 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. (We)agree to save 180 DAY F OM LAST CALLED INSPE TI N.
indemnify acrd keep harmless the Cit'of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the t/ //
granting of this ermn, Add iliona11 the applicant understands and wi11 comply. Issued by: Dater Y
with all non-po ourceregula'ons per the Cupertino Municipal Code,Section
9.18.
RF.-ROOFS:
Signature Date t/ / �� All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,Iagree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of,ApplicanC Date:
the following two reasons: ALI.ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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(Sce.7044,
Business&Professions Code)
I,as owner of the property,run exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
consimct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California health&Safety Code,Sections 25505,25533,and 25534. 1 will
hereby affirm under penalty of perjury one of the following three maintain compliance with'.the Cupertino Municipal Code,Chapter 9.12 and the
declarations: health&Safety Code,Section 25532(x)should I store or handle hazardous
I have andwill 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 Ray Area.Air Qualfty Management District
performance of the work Rur which this permit is issued. will maintain compliance withthe upertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code.Sccti s 50aand 25534.
Section 3700 of the Labor Code,for the perfamvunce of due work for which this 7
permit is issued: /� e7
Owner or authorized agent- Date:
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 die Worker's
Compensation laws ofCalifomia. If,after making this certificate of exemption,I CONSTRUCTION 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, work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Leader's Address
I certify that I have read this application and state that the above infommtion 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, ARCIIITECT'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: $5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE: Al
WORK Deck Repair 224 sq ft).
SCOPE
Much. Plon Check Plumb. Plan Check Flec..Plan Check
bleed. Permit Fee: Phmrh.Permit Fee: Flec•. Permit Fee:
Other,llech.Insp. Other Plumb Insp. Other Elce.Insp.
Atech.hmp.Fee: Phanb. hmp.Fee: Flee.Lisp.Fee:
NOTE: This evinrnte does not include feev due to other Departments(i.e. Planning, Public Narks, Fire,Sanitary Server District,School
District,etc. . These feev are based on the prefintinan information available and are attdv an estimate. Contact the De t or addn7 info.
FEE ITEMS (Fee Resolution 11-053 Efl 7/1/111 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Deck/Deck Railing
Suppl. PC Fee: Q Reg. Q OT FO.0 hrs $0.00 $467.00IDECK I'OOD Deck (wood)
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee0 Reg. Q OT F0.0 1 hrs $0.00
PMH Unit Fee: $0.00
PME Permit Fee: $0.00
Convruction Tar:
:9dminictrulive Fee:
Work Without Permit? O Yes Q) No $0.00
Advanced Planning Fee: $0.00 Select Non-Residential E)
Travel Docrnnentatinn Fees: Building or Structure 0
Strong Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item
131dg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $467.00 TOTAL FEE: $468.50
Revised: 10/01/2012
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 0El
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 \�\
CUPERTINO (408)777-3228• FAX(408)T77-3333• buildina(alcuoertino.orn
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COHTNACTOR NAME , ( ✓tom\� LICENSE NUMB L /6 <?r LC'FNSE TYPE j3 BU&UC.
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ARRGrEU1FNGINEfIlNA11(E s J LICENSE NUNMER BUS.uce
COMPANY NAME [� E-MAB. FAX
STREET ADDRz3S JJ QTY.STATE.W PHONE
DESCRIPTION OF WORK /l,q C. 0
FJ[STMGISE PROPOSIDUSE CONSTR.TYPE 1STDRRS
USE TYPE OCG SQFT. VALUATSON(S)
0= NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA -
RATFDtOOM KITCHEN OTM
REMODELAREA REMOOELAREA REWDEL AREA
POR AREA DF AAEA TOTAL nECR/M�AREA GARAGE AREA DETACH
ATTACH
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• RKING"Dan? OmADomorc ONO pJr U b.O O
PRILAPFUCATTON ❑YES tP YES,PROVIDE COPY OF STEatz; GAN OYES RECQVFD BY: TOTALVALUATION:_
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By my signatme below,I certify to each of the following I am the property owner or authorized agent to act on the prppary owner's behalf I have read this
application and the iaformatirm I vided is conecL I have read the Description of Work and verify it is acuate. I agree to comply with an applicable local
aDlinances and state bras¢ladng drop or. I a¢Thorize representatives of Cupertino to enter the above-identified property ff^o•�rr mspaction proposes.
SigDznae of Applicant/Agent Date: �r/ *l4`
SUPPLEMEIV'CALINFORMAT[ONREQUiREDPUN�CECTris Romutcav
New SFD or Multifamily dwellings: Apply for dertolitim permit for Oval-TEM-COmRRR �CBDa.Dwc PIAN aRvew
msdng btuldmg(s)..Demolition permit is required prior to isstumoe of bmlding
permit for new bmlding. ❑ aaeEcs ❑ PL QUWC PLAN RrVTEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ srw oro ❑ I'O c woaro
Corm if my Hazardous Materials are being used as part of this pmj=L ❑ L GE ❑ rms bur
_Copy Of Planning Approval Leder or Meeting wide Planning prior to ❑ esvoR ElsANLrARY sEWm DtrrRtcr
submittal of Building Permit application.
❑ EMVEROMM12fTAL EMALTH_
dldgApp_2011.doc revised 06/31/11