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11090128CITY OF CUPERTI�'1jO BUILDING PERMIT BUILDING ADDRESS: 10234 PARKWOOD DR I CONTRACTOR: AVERY PERMIT NO: 11090128 OWNER'S NAME: AVERY GLENBROOK LP .YNER'S PHONE: 6509618330 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor Date 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: 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. 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 permit is issued. APPLICANT CERTIFICATION I certify that 1 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 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, costs, and expenses which may accrue against said City in consequence of the 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. GLENBROOK LP 130 E DANA ST ] DATE ISSUED: 09/20/2011 MOUNTAIN VIEW, CA 94041-1508 1 PHONE NO: F_ f— F BUILDING PERMIT INFO: BLDG ELECT PLUMB F_ 1_ F MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: ALL UNITS- MULTI -FAMILY REPLACE 8 WINDOWS NON-STRUCTURAL BEDROOMS TO MEET EMERGENCY RESCUE AND ESCAPE. Sq. Ft Floor Area: I Valuation: $20000 APN Number: 32627037.10234 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. l ' L Issued by: �/� Date: 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 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following threeO 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. 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 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 +emnify and keep harmle the City of Cupertino against liabilities, judgments, .sts, and expenses whi ma ccrue against said City in consequence of the granting of this permi A ti nally, t derstands and will comply with all non -point re I ' ns per the Cupertin Municipal Code, Section 9.18. .._ Date Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equ' ent or devices which emit hazardous air contaminants as defined by the B rea Air Quality Management District 1 will maintain compliance with thetbfertino ode, Chapter 9.12 and the Health & Safety Code, Sectio, 25533, and 255 Owner or authorized a t Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: U3 t� t.�'�kr PERMIT # OWNER'S NAME ,, -- ^ I4�-II✓o ok L- PHONE # GENERAL CONTRACTO 6' 13 BUSINESS LICENSE # ADDRESS: x CITY/ZIPCODE: E> r,'J Cj "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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting )l inoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building ancupertino.org 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 0 Z 3 APN gp# OWN NAME 7 V Zsllz y 6 Lq,-i-rz a4L CP OWNER ADDRESS ('30 DESCRIPTION OF WORK: W i --� 'to,N \ \& C.X-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 in�ra e coverage for injuries to workers on my property. 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. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that 1 -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 ZI vue of my construction is at least five hundred dollars ($500), including labor and materials, I may be red an "employer" under state and federal law. fi6 1 understand if I am considered an "employer" under state and federal law, I must register with the state and e rai 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. 1 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, med under contract with a licensed general building Contractor. 8. 1 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 elects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 0y/ 9 1 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.csib.ca.gov for more information about licensed contractors. 10. 1 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. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide V11aable laws and requirements that govern Owner -Builders as well as employers. gree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the 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.) 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 pee table to the be required to be presented when the permit is issued to verify the property owner'ssign Property Owner's Signature: Date: 9 _0� --------------------------------------------------------------------------------------------------------------------------------------------- (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: Address of Authorized Agent: Tel No 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: OwneBuilde"Form 2010.doc revised 04/14/10 CITY OF CUPERTINO 3 ITEMS OF 30 PERMIT RECEIPT OPERATOR: SylviaM COPY # : 1 Sec: Twp: Rng: Sub: Elk: Lot: APN 32627037.10234 DATE ISSUED.......: 09/20/2011 RECEIPT #........-: BS000014804 REFERENCE ID # ...: 11090128 SITE ADDRESS .....: 10234 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 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(cDcupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED iIc)(51o(2k ORIGINAL PEPUNUT # PROTECT ADDRESS CJ L �G`9 ri LU C)(`) C ��' APN # O �� ✓ OWNER NAMEX V L� �/ l P ` ✓ PHONE G_.� -O - n 6(_ � 7 E-MAll d7 ,AvC� �S �z7Yvl-4,1 STREET ADDRESS CITY, TATE. ZIP n vy✓/—,.a,w lir' F � -+ O/ ed 3 O�. �� � S� � , ,c.,�,� CONTACT NAME S�(; ✓C '-�LLUA�CIC PVC7ZNF�-fsU6- �% y"1� j E7/C ISLV STREET ADDRESS Z;70i I CITY, STATE ZIP F ❑ OWNER ❑ OWNER -BUILDER ❑P OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT � ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME „ �C LICENSE NUMB Co 5(, LICENSE TYPE BUS. LIC # E'v VC1 ✓1C -c COMPANY NAME1 E-MAIL >� C4 IZ� F `7 ��' 73� r' e .re l u n I v h l�t�tc;,t, STREET ADDRESSC -F�� y� CITY, STATE, M? �b moat-?: l: �i v. C S yI ~ Vct P ONE ARCHITECT/ENGINEER NAME 1 J.�l_ t�f 4T LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAM FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK S S /T>, w 02 ? C -UL S L aF+ EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FI'. VALUATION (S) EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA - BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES BEING ADDED? []NO SECOND STORY ❑ YES ADDITION? []NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL # ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prrperty 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 ordinances and state laws relating u ding c tion. I authorize representatives of Cupertino to enter the above -i entif d property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ oma-.TBE-COUN.I.ER ❑ BUMDI*NG PLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit for 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 C3sTANDmw ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project.LARGE ❑ ❑ >;mEnEPr _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH . BldgApp 2011.doc revised 06/21/11 'k- 9,71 . 97!