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11090132 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10140 PARKWOOD DR CONTRACTOR:AVERY GLENBROOK LP PERMIT NO:11090132 OWNER'S NAME:,AVERY GLENBROOKCLP 130 E DANA ST DATE ISSUED:09/20/2011 OWNER'S PHONE: 6509618330 • MOUNTAIN VIEW,CA 94041-1508 PHONE NO: ❑ LICENSED CONTRAC/nT�OR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIALS License Class 1 Lic.it `1 a q pc ALL UNITS-MULTI-FAMILY REPLACE 8 WINDOWS . �� �Q NON-STRUCTURAL BEDROOMS TO MEET EMERGENCY Contractor S ,.. l-Qvows.` Date 0 /a�I( 3 RESCUE I hereby affirm that I am licensed under the provisions of Chapter 9 AND ESCAPE. ,p G C�.�"a W 1 no�ere..Tj (commencing with Section 7000)of Division 3 of the Business&Professions 2 �,; Z �w�I'�'-�1t. Code and that my license is in full force and effect. 2• Z R.Mei,n 40 T4-c S eon o 4 wear k. I hereby affirm under penalty of perjury one of the following two declarations: N2t� t�Gs p A'4 •1• yv l l *gots I have and will maintain a certificate of consent to self-insure for Worker's 1 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 I 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:32627037.10140 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 WITIIIN 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 DA n r • i' LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses whichmay accrue against said City in consequence of the Issued by: Date: � '�''L (� granting of this permit. Additionally,the applicant understands and will comply with all non-poir.t source re ulations per the Cupertino Municipal Code,Section • 9.18. t �) RE-ROOFS: Signature - Date `� 0 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. 0 OWNER-BUILDER DECLARATION Date: Signature of Applicant: I hereby affirm that I am exempt from the 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 thcwork,'and the stmcture.is not intended or offered for sale(Sec.7044, Business&Professions Code) • HAZARDOUS MATERIALS DISCLOSURE • I,as owner of the property,am exclusively;contracting with licensed contractors to 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. I 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(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 I • performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and Health& Safety Code,Sectio 25505, _533,and 25534. I have and will maintain Worker's Compensation Insurance,as provided for by the /. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: •S�stiff Date:61 :90 j 2 permit is issued. i 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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 . Inspection Data Sheet- 8/15/2003 Permit 1992-22897-00 Issued 10/1/1992 Location 20917 Greenleaf Dr.,Cupertino,CA 95014 Zone 2 Fees Cross Street Stelling Building 93.00 Owner Belle M PlanCheck 70.00 Contractor SELF Planning 55.00 Electrical 7.00 Owner Phone 996-0590 Job Desc Tool Shed&Storage Structure ❑Geology ❑Land Develop 0 Planning ❑Roads/Airports 0 Environ Health 0 Fire Marshal ❑FE Called Date Insp Phone Code 1 2 3 4 5 Request 8/14/03 1:59:16 PM 8/15/03 2922173 ST16 ST16 ST16 0 0 Note Code Comments Date Insp Disposition STO2 FOUNDATION FORM/REBAR CORR 10/22/92 JRD Disapproved STO2 FOUNDATION FORM/REBAR CORR. 10/29/92 REW Disapproved STO2 FOUNDATION FORM/REBAR 11/2/92 JSH Approved STO7 GIRDERS& NOENT 2/2/93 WFC No Action JOISTS/UNDERFLOOR STO7 GIRDERS& 2/3/93 NRV Approved JOISTS/UNDERFLOOR ST14 SHEETROCK NAILING 518 TYPE X AT N.WALL 5/25/93 JRD Partial Approval ST14 SHEETROCK NAILING 5/8 TYPE X AT N.WALL 5/25/93 JRD Partial Approval STO9 SHEAR NAILING 8/17/93 JEP Approved EL04 ROUGH WIRING 8/17/93 JEP Approved ST10 ROOF NAILING/SHEATHING 8/17/93 JEP Approved ST14 SHEETROCK NAILING REST OF TYPE X 8/17/93 JEP Partial Approval F101 PROJECT COMPLETED 617/94 MLH Approved EL08 ELECTRIC FINAUFIXTURE 6/7/94 MLH Approved printed 2/20/2013 2:57:37 PM page 1 • • ;In nu n.n frT foe mwom w • Cr 7; gra • ill 12.Y r r. sanrs sonny mu .w. 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'Q ; zi 3 1 JIll . gAi ; iii 4 1 I s II 18 II i i -- CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10140 PARKWOOD DR CONTRACTOR:AVERY PERMIT NO: 11090132 GLENBROOK LP OWNER'S NAME: AVERY GLENBROOK LP 130 E DANA ST DATE ISSUED:09/20/2011 ` ;1NER'S PHONE: 6509618330 MOUNTAIN VIEW, CA 94041-1508 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# r f- I- MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION: ALL UNITS-MULTI-FAMILY REPLACE 8 WINDOWS I hereby affirm that I am licensed under the provisions of Chapter 9 NON-STRUCTURAL BEDROOMS TO MEET EMERGENCY RESCUE (commencing with Section 7000)of Division 3 of the Business&Professions AND ESCAPE. 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:$20000 I 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:32627037.10140 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, �jTs. 1 ��` I costs,and expenses which may accrue against said City in consequence of the Issued by: �/✓ Date: granting of this permit. Additionally,the applicant understands and will comply 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 being 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: I hereby affirm that I am exempt from the Contractor's License Law for one of 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 contra t 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. I 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(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 equip 'ent 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 , ea Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the C .erti I. . i nlcapa o.•, hapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio i 5533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this '"1— -4..01000"'"'"----- Ze 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 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 ARCHITECT'S DECLARATION ndemnify and keep harmles r City of Cupertino against liabilities,judgments, costs,and expenses whicA y accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permits'.'-.nally,the a..1 .. t understands and will comply with all non-point so - . ••- .er the Cupertin. , unicipal Code Section Licensed Professional 9.18. ' Signature, Date 'l l 1/ CITY OF CUPERTINO 3 ITEMS OF 30 PERMIT RECEIPT OPERATOR: SylviaM COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot : APN • 32627037 . 10140 DATE ISSUED • 09/20/2011 RECEIPT # • BS000014804 REFERENCE ID # . . . : 11090132 SITE ADDRESS • 10140 PARKWOOD DR SUBDIVISION CITY • CUPERTINO IMPACT AREA OWNER • AVERY GLENBROOK LP ADDRESS • 130 E DANA ST CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94041-1508 RECEIVED FROM • AVERY CONSTRUCTION CONTRACTOR • TBD - TO BE DETERMINED LIC # 00096 COMPANY • TBD - TO BE DETERMINED ADDRESS CITY/STATE/ZIP . . . : , TELEPHONE FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL 1BCBSC VALUATION 20, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 20, 000 . 00 2 . 00 0 . 00 2 . 00 0 . 00 1WINREP EACH 8 8 . 00 392 . 00 0 . 00 392 . 00 0 . 00 TOTAL PERMIT : 395 . 00 0 . 00 395 . 00 0 . 00 / Building Department City Of Cupertino -‘11V 10300 Torre Avenue ,-( 19,� Cupertino, CA 95014-3255 � Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: (0 ( -1O I).c r/Lira e 1'r" PERMIT# OWNER'S NAME: A,,i PV' � t'vi br (Z PHONE# fO - 011-5.36:7/'/O6'-%cXX yl yli GENERAL CONTRACTOR o 1 BUSINESS LICENSE# ADDRESS: /30 E (DC(vitt S 1 CITY/ZIPCODE:Gfl,11 (); e.w cr!C) if *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPA/r INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUB 4 NTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: �� IIIL ¢1/40// Signature Date Please check applicable subcontractors and complete the following information: 6/ 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 Re• Ti - 9A// Owner/Contractor Signature Date I \0"1/, OWNER-BUILDER DISCLOSURE FORM ..(1.& COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building a cupertino.orq Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS/ b/L(v -�sz..�,,,,o,h Th� APN BP# OWN VASE Y 6 L� 3Rv (_P OWNER(30 ADDRESS EL .. 1::.A.✓P' sf elk 0.),v L-C-" DESCRIPTION OF WORK: W i '-'b 'VQ .AJ A ''--�• We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECT ONS:Please read and initial each statement below to signify you understand or verify this information.) 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Bu der" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my ins rance coverage for injuries to workers on my property. 2. I understand building permits are not required to be signed by property owners unless they are responsible for th 7nstruction and are not hiring a licensed Contractor to assume this responsibility. . I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may tett myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her na a instead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license tubers on permits and contracts. . I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the t I value of my construction is at least five hundred dollars ($500), including labor and materials, I may be onsidered an"employer" under state and federal law. i6. I understand if I am considered an "employer" under state and federal law, I must register with the state and f eral government, withhold payroll taxes, provide workers'compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me o serious financial risk. 7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family r idential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by tensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is perf. ed under contract with a licensed general building Contractor. 1 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for (y financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction .efects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I a he arty legally and financially responsible for proposed construction activity at the site address listed above. 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by II a 'cable laws and requirements that govern Owner-Builders as well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the formation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, thi form must be completed and signed by the property owner and returned to the agency responsible for i uing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verification _ eatable to the ' H. be required to be presented when the permit is issued to ver' the .ro•ert owner's .gn_ids Property Owner's Signature: Date: 947:37// (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwneBuilderForn1 2010.doc revised 04/14/10 \op./ CONSTRUCTION PERMIT APPLICATION I�•° COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISIONB 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 e1'''.1. (408)777-3228• FAX(408)777-3333 • buildinq(acupertino.orq °I r CUPERTINO 1169 l3 ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI El REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS /C) I / v dr; r� Lv C',,{Y` APN# 2 Z/ .21 b3-7 . 16I t l O OWNER NAME !( l• PHONE E-MAIL ,Ave `�S `� c r �v�72 Y 67 t r�320Oi , to 6s-o-960-,Y3�D A / !-� e IOWA-4 STREET ADDRESS _ CITY, TATE,ZIP rJ a FA�i+� j.si y L �O Cj.i/ - .Z7/ 3 o a 5+- 0 vs,/ w 1 .w ell W CONTACT NAME ) S't(_S ✓L_ p iL L V A tJ C,C--. P,ko -s-U€- 9 7 `f)J E I TL t'= A l0..a Q 6 /Lt, • :4-1Z STREET ADDRESS s. r(c�! / (r` uGLruif lAil V1 y Volle c-, f Ya CJ 1 ,-cog L l — (6.4 El ❑ OWNER-BUILDER 0 OWNER AGENT I -0...TRACTOR ❑CONTRACTOR AGENT / 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT CONTRACTOR NAMES/e VZ° pie uCi.Y1 C` ne LICENSE NUMBED j � �+/ y LICENSE TYPE 3 BUS.LIC# r� /� E-MAIL `( 6 F• `t a.fig-7V- �4�© COMPANY NAME Sk sic p iev n<<< co h s c,F7�� ,s-�.e ve p6 u 6 ma, l,cv l S CITY,STATE,ZIP PHONE STREET ADDRES fi� S.inn ,'Id a,,,e, 01 S c> i n j&c 1 k<(-14. g 1tc , /roe -50C, --9/`1-$ ARCHITECT/ENGINEER NAME 61, 1.AT_ LICENSE NUMBER BUS.LIC# COMPANY NAME �f YE-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK ` \ tV�7 ti'�`.°`•C.-Lam^,. c-.1f3,- l-�Q.,I"--, i I.A..--1-‘1.i t J "-e..-w1, C.--s. wJ be v,C I(Z(„n' 5 r 5/b,,e /..4 0.v a& / 12-0-C S L A-4-j K cj, n f.(` j, > EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES `Z_ USE TYPE OCC. SQFT. VALUATION(5) EXLSTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA - BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LI DETACH ❑ATTACH #DWELLING UNITS: ISA SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? ONO PRE-APPLICATION DYES IF YES,PROVIDE COPY OF IS THE BLDG AN 0 YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL# ONO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO 0 r 0.2----- - By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prpperty owner's behalf. I have read this application and the information I ha!a.rovided is correct- I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local .I ordinances and state laws relating . ding c./ail Date:don. I authorize representatives of Cupertino to enter the abov�e;-i tifiproperty for inspection purposes. (Signature of Applicant/Agent: -' "LW C-j p(,J/ I SUPPLEMENTAL INFORMATION REQUIRED PLAN Ca.e.CK TYPE ROUTING SLIP —New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure CISTANDARD EI PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. CI LARGE ❑ FiRz DEFT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT I submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH. •BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10270 PARKWOOD DR CONTRACTOR:AVERY PERMIT NO: 11090134 GLENBROOK LP OWNER'S NAME: AVERY GLENBROOK LP 130 E DANA ST DATE ISSUED:09/20/2011 'WNER'S PHONE: 6509618330 MOUNTAIN VIEW, CA 94041-1508 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION 1- r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.ti 1- I- MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ALL UNITS-MULTI-FAMILY REPLACE 8 WINDOWS NON-STRUCTURAL BEDROOMS TO MEET EMERGENCY RESCUE (commencing with Section 7000)of Division 3 of the Business&Professions AND ESCAPE. Code and that my license is in full force and effect. I 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 I 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:32627037.10270 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, �� costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: �1 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 being installed.If a roof is 7.---' installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of 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 o HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have.read the hazardous materials requirements under Chapter 6.95 of the alifornia Health&Safety Code,Sections 25505,25533,and 25534. I 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(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 equi I• ent 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 • rea Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the C .ertino Munici ea!Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio,-- 533,and 534. Section 3700 of the Labor Code,for the performance of the work for which this g 2//,� permit is issued. Owner or authorized a en •L 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 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 he •0 authorize representatives of this city to enter upon the above mentioned pr..e y for inspection purposes.(We)agree to save 'lemnify and keep harmle' t'e City of Cupertii• ..t•'o _liabilities,judgments, ARCHITECT'S DECLARATION as,and expenses whic' m,► .:cc uaaginst said City in co sequence of the I understand my plans shall be used as public records. granting of this permit. •.• :'y,the applicant under • i s_wu.d.will comply with all non-point soiregu atio ,r omoom.'T __`mo Municipal Code,Section Licensed Professional 9.18. Signature Date 0 ( l f \ / Building Department City Of Cupertino 10300 Torre Avenue S1.19 Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: lb 'Z7 PERMIT# OWNER'S NAME: e.v;.& r L P PHONE# ,4). -9/ �fs� GENERAL CONTRACTOR: c;( 1 BUSINESS LICENSE# ADDRESS: ► 3 o e.. n-u q 1& CITY/ZIPCODE: ✓c /c-'- 9"cee *Our municipal code requires all businesses working e city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUP / Y INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL S . :Tj_ ORS HAVE C BTAINED A CITY OF CUPERTINO BUSINESS LICENSE. , I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood lass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 9/t- Owner/Contractor Signature Date i1 \\' 1jOWNER-BUILDER DISCLOSURE FORM IF) COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 4.",-,,,s 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building( cupertino.orq Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# O 270 .tt.- ,A-ici') -S,R OWNFR NAME OWNER ADDRESS l �L — ' 6 Le,),-3,,,,,,t_ CP (30 O. UA.r'A S+ "Lt.() C . �({ 0 DESCRIPTION OF WORK: W i 1-3 v? d P A�-,--4---. We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECT ONS:Please read and initial each statement below to signify you understand or verify this information.) 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Bu der" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my ins rance coverage for injuries to workers on my property. 2. I understand building permits are not required to be signed by property owners unless they are responsible for th construction and are not hiring a licensed Contractor to assume this responsibility. 3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her na a instead of my own. ,_ 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license tubers on permits and contracts. . I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the t I value of my construction is at least five hundred dollars($500), including labor and materials, I may be onsidered an"employer" under state and federal law. feral government, withhold payroll taxes, provide workers'compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me o serious financial risk. 7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family r idential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by tensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is pelf. ed under contract with a licensed general building Contractor. J 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for o`y financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction /'elects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 ' 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I a he arty legally and financially responsible for proposed construction activity at the site address listed above. 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by II a 'cable laws and requirements that govern Owner-Builders as well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the formation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued,thi form must be completed and signed by the property owner and returned to the agency responsible for i uing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verification -' e.table to the ' m. be required to be presented when the permit is issued to ver' the •ro•ert owner's 'gn. •fgS Property Owner's Signature: 4111111to Date: 9 _ // (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 \�/� CONSTRUCTION PERMIT APPLICATION 1�•,J COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ��s„Ss 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• buildinq(a,cupertino.orq I 16 1 O f 2� CUPERTINO 1 J ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMITI 1 -70 0PROTECT ADDRESS +1 9, ui (. c (,A \ r # 7 1.9 2I ()al_ 1 lJ 240 •OWNER NAME I/L7z 6JPHONE .521.9 E-MAIL ^dYvC �Sp z C-4c.• „ � 1.3_3rzopiC, 1..... to 6s"o-96/- 2(33D STREET ADDRESS ___ CITY, TATE.ZIP /7 n Fr , O,j'•I •Z7/ CONTACT NAMEI , Q /' G S 1-C'J C_ 7 &e V ArJ Ct C_ P`c0, --$O 6' 9, `�')r E S Au7`Clet"_t1 1-.a /km__ 6 • STREET ADDRESS goxi5. �1ter/1ic (ifG`�n ,k 0 ZIP L]f�a (e rCGA _ ,fo G 1 FAX -713 -/q (.6,4 0 OWNER El OWNER-BUILDER 0 OWNER AGENT (]!CONTRACTOR ❑CONTRACTOR AGENT ! 0 ARCHITECT 0 ENGINEER 0 DEVELOPER ❑ TENANT CONTRACTOR NAMEpie vot rt CA LICENSE NUMBLICENSE TYPE BUS.LIC# CI .1:3 J j �c, E-MAIL F' `ra-7V.^ !4 66, COMPANY NAME sI-e ue- Pl1va.nc,L (oh .s rr ,1 ,.S- p ie° �'C.; Ma, 1, d)11 =:, .i: STREET ADDRESS CITY.STATE.ZIP PHONE S.Moak-1.14 a v� S ti-4 h i vci lc,c--1,4- q 4'ci - , 404. -50& -9/ `is' ARCHITECT/ENGINEER NAME (1, 7/YT/1_ LICENSE NUMBER BUS.LIC# COMPANY NAME � E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK `A(. i v F ; c__s -I-0-,-,5 , 9,b,', y„r o k.02 / ?zQ c S C-A4-_-5 j tL'i 1,“ e LL'i EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: U DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT 0 YES SECOND STORY 0 YES BEING ADDED? ONO ADDITION? ONO PRE-APPLICATION OYES ff YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL INVALUATION:_ PLANNING ONO PLANNING APPROVAL LETTER EICHLERHOME? ❑NO 3 ZC)r OOU By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prpperty owner's behalf I have read this application and the information I ha e.rovided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating .3.1 ding c. :'i tion. I authorize representatives of Cupertino to enter the above-I entified operty for inspection purposes. lip a Signature of Applicant/Agent: =•��� , Date: , 9 0 1/ SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-TBE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. 0 EXPRESS 0 PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 0 STANDARD ElPUBLIC WORKS form if any Hazardous Materials are being used as part of this project. 0 LARGE ❑ EIRE WEPT _Copy of Planning Approval Letter or Meeting with Planning prior to 0 MAJOR ❑ SANITARY SEWER DISTRICT abmittal of Building Permit application.1 CI ENVIRONMENTAL HEALTH •BldgApp_2011.doc revised 06/21/11