11100134CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10110 PARKWOOD DR I CONTRAC TOO STEVE PLEVANCIC I PERMIT NO: 11100134 I
NAME: AVERY GLENBROOK LP
528 S MATHILDA AVE STE 2 1 DATE ISSUED: 10/24/2011
R'S PHONE: 6509618330 I SUNNYVALE, CA 94086 PHONE NO: (408) 806-9145 I
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # % 7� 6
Contractor Ste_ c ij fG A'1 e—' C Date r/ U o'(
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 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,
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.
Signatur Date
to ��
L_ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
unify and keep harmless the City of Cupertino against liabilities, judgments,
, 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.
Signature Date
BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB I—
MECH r— RESIDENTIAL f— COMMERCIAL
.TOB DESCRIPTION: ALL UNITS- REPLACE 20 WINDOWS LIKE FOR LIKE
Sq. Ft Floor Area: Valuation: $20000
APN Number: 32627036.10110 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date:/� Z L
Issued b[—
y`
RE -ROOFS:
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.
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. 1 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 equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
O r ar ori d agent: �'
' Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of mrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • building(Qcuperbno.org
CUPERTINO I i I MI3�
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DUU= ORIGINAL PERMIT #
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N DWELLING UNITS:
IS A SECOND UNIT YES
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
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TOTAL DECK/PORCH AREA
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N DWELLING UNITS:
IS A SECOND UNIT YES
SECOND STORY OYES
BEING ADDED? []NO
ADDITION.' ❑NO
PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF
PLANNING APPL A ❑NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
REQ BY:
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OTAL VALUATION:
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By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the pr9perty owner's behalf. I have read this
application and the information I ha a vided is correct 1 have read the Description of Work and verify it is accurate. I afire to comply with all applicable local
ordinances and state laws relating ding c on. I authorize representatives of Cupertino to enter the above -i
ti$ property for inspection purposes.
Signature of Applicant(Agent
Date: )
SUPPLEMENTAL INFORMATION REQUIRED
?I-, CxTYPE
TI
ROUTING SLIP
Q BvtLDnvG PLAN REvtEw
New SFD or Multifamily dwellings: Apply for demolition permit for-I��ovlrrER
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
Cl MR=
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORM
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE bKrr
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY srwot DISTRICT
%ibmittal of Building Permit application.
❑ ENVIRONMFNTAL HEALTH
im
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B1dgApp_ Ol Ldoc revised 06/21/11
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CITY OF CUPERTINO
3 ITEMS OF 33 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32627036.10110
DATE ISSUED.......: 10/24/2011
RECEIPT #.........: BS000015126
REFERENCE ID # ...: 11100134
SITE ADDRESS .....: 10110 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 ....: ACCO MANAGEMENT CO
CONTRACTOR ........: STEVE PLEVANCIC LIC # 32967
COMPANY STEVE PLEVANCIC CONSTRUCTION
ADDRESS 528 S MATHILDA AVE STE 2
CITY/STATE/ZIP ...: SUNNYVALE, CA 94086
TELEPHONE (408) 806-9145
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
20.00
652.00
0.00
652.00
----------
0.00
----------
TOTAL PERMIT
----------
655.00
----------
0.00
655.00
0.00