13020024 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10240 PARKWOOD DR CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 13020024
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED:02/06/2013
OWNER'S PHONE: 6509618330 SUNNYVALE,CA 94086 PHONE NO:(408)806-9145
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
11
License Class Lia N ( -7 b q!O UNIT 64-6**DECK REPAIR**
Contractor Sb c Date 06 0
I 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.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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 be performance of the work for which this APN Number:32627037.10240 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 DA 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 CALLED INSPEC I713 indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 2 6
granting of this permit Additionally,the applicant understands and will comply Iss Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am exempt from[M1e Contractor's License Law for one of
the following two reasons: ALL 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(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I 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 and will maintain a Certificate ofConsentto 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 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 533,and 25534.
Section 3700 of the Labor Code,for be performance of the work for which this
permit is issued. Owner or authorized agent: �—� Date: Q
&4)
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 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 Lender's Address
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, 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
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U PE RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: O yo a PAr — PERMIT#
OWNER'S NAME: W e er'" PHONE # a If
GENERAL CONTRACTOR: et/'t BUSINESS LICENSE#
ADDRESS: Glue L�-- CITY/ZIPCODE: h n of R 4ar G
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCON RACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: ( r r — do6b 3h
Signature Date
Please check applicable subcontractors and complete the following information:
t/ 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
co-A) C,/(
O ner/Contractor Signature Date
CONSTRUCTION PERMIT APPLICATION 00v
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION v
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 117 b
CUPERTINO (408)7 -3228•FAX(408)777-3333•buildina(abcuoertirro.om
❑NEW CONRUCRON �a✓ADDITION
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STREET ADDRESS CITY.STATE,ZIP PHONE
DESCRIPDON OF WORK e
FASTING USE PROPO.SEDUSE CONSTRTYPE Isroxis
USE TYPE OCG SQ-Fr. VALUATION(S)
ERLSTO NEWFLWR DEMO TOTAL
AREA AREA AREA HFr.AREA -
BATHROOM PaCHEN OTHER
REMODELAREA REMODE.AREA RE WDEL AREA
PORL3i AREA DEMAREA TDTALDECIVPORCIfAREA GARAGEAREA, DETACH
❑ATTACA
I DWELLING UMTS: SASECONDUNIT YES SEGOHD STORY YES
SUNG ADDED! ❑No ADDTLWN' ❑m
PRE-APP rvoei ❑YES WYEK mcvmEcoPYOF STBR stoc AH ❑YES RE Y TOTAL VALUATION:
KANIN GAPPLP ONO PLAMiKGAPPROVALLEITFR EIClu"Ro"Er ❑NO
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By my signature below,i ratify to each of the fbIlowmg I am the property owner or aothor=d ontit erty owner's behalf I have read this
applicatimt and the mforrr ad Ilia mvided is correct I have read the Description of Work and verify it is I agNx m comply with allapplicable local
ordinances and state Ims nhtting divg c tioa I authorize representatives of Cupetmto to enter the above-identified property for inspection proposes.
Sigaaume of ApplimintlAgam Date:
SUPPLEMENTAL INFORMATION REQUIRED PLAN QLTYrE Roma+c sw
New SFD or Mtdtifatmly dwellings: Apply for demolition permit for ❑ OVED..THECOUN TER ❑ BUILDING PLAN REVIEW
egg brild'mg(s). Demolition permit is required prior to issuance of building
permit for new btttld"mg. ❑ ❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed H=wdow Materials Disclostae ❑ srAmuARD ❑ POBLSC woRLo
form if any Hazardous Ma=als are being used as part of this projecL ❑ .RG, ❑ FIRE nrrr
Copy of Planning Approval Lena or Meeting with Planning prior to ❑ MAJOR ❑ &kMrARY SEWER DMMCr
submittal of Building Permit application.
❑ ENvmormmvrAL HEAL-1a
dldgApp 2011.docrevised0&21/11