11100125CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10268 PARKWOOD DR
CONTRACTOR: STEVE PLEVANCIC
PERMIT NO: 11100125
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP
528 S MATHILDA AVE STE 2
DATE ISSUED: 10/24/2011
4ER'S PHONE: 6509618330
SUNNYVALE, CA 94086
PHONE NO: (408) 806-9145
❑ LICENSED CONTRACTOR'S DECCLARATION
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BUILDING
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PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. # ! (o
PGA
MECH RESIDENTIAL COMMERCIAL
Contractor < Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: ALL UNITS-- REPLACE 24 WINDOWS LIKE FOR LIKE
(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.
l have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $20000
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 32627037.10268
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
-orrect. I agree to comply with all city and county ordinances and state laws relating
PERMIT EXPIRES IF WORK IS NOT STARTED
�o building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
,osts, and expenses which may accrue against said City in consequence of the
;ranting of this permit. Additionally, the applicant understands and will comply
,vith all non-poi pt source regulati the Cupertino Municipal Code, Section
Issued by:Date: J�Z 4—
�.18.
signature 4 Date w ��
RE-ROOFS:
OWNER-BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
:he following two reasons:
inspection.
as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
Nill do the work, and the structure is not intended or offered for sale (Sec.7044,
3usiness & Professions Code)
, as owner of the property, am exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
;onstruct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
leclarations:
I have read the hazardous materials requirements under Chapter 6.95 of the
have and will maintain a Certificate of Consent to self-insure for Worker's
California Health & Safety Code, Sections 25505, 25533, and 2.5534. I will maintain
ompensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
>erformance of the work for which this permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
lection 3700 of the Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District I will
>etio is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
certify that in the performance of the work for which this permit is issued, I shall
Health & Safety Code, Sections 25505, 25533, and 25534.
iot employ any person in any manner so as to become subject to the Worker's
.ompensation laws of California. If, after making this certificate of exemption, I
O r aut iz agent:
Date:
Become subject to the Worker's Compensation provisions of the Labor Code, I must
orthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of "ark's
APPLICANT CERTIFICATION
for which this permit is issued (Sec. 3097, Civ C.)
certify that I have read this application and state that the above information is
Lender's Name
orrect. I agree to comply with all city and county ordinances and state laws relating
a building construction, and hereby authorize representatives of this city to enter
Lender's Address
ipon the above mentioned property for inspection purposes. (We) agree to save
,mnify and keep harmless the City of Cupertino against liabilities, judgments,
, and expenses which may accrue against said City in consequence of the
ARCHITECT'S DECLARATION
tinting of this permit. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
vith all non-point source regulations per the Cupertino Municipal Code, Section
1.18.
Licensed Professional
signature Date
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255
AX 408 777 3333 • b dd' (a7 rti
--- (408) 777-3228 • F ( ) - ui ing _cupe no.org
CUPERTINO I I
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❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI [I REVISION/DEFU= ORIGIN PERMIT #
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❑ OWNER ❑ OwNER-BiniDER ❑ OWNER AGENT W CONTRACTOR ❑ CONTRACTOR AGENT
❑ ARCHITECT ❑ ENGWEER ❑ DEVELOPER ❑ TBqANr
CONTRACTOR NAME '
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LICENSE NUMBL(
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COMPANY NAME
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ARCHTI'ECT/ENou4EER NAME ► ) iL
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LICENSE NUMBER
PORCH AREA
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COMPANY NAME
GARAGE AREA DETACH
E-MAIL
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STREET ADDRESS
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CITY, STATE, ZIP
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DESCRIPTION OF WORK
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EXISTING USE
PROPOSED USE CONSTR.
TYPE
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TYPE
OCC,
SQ.FT.
VALUATION (5)
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DEMO
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TOTAL
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BATHROOM
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REMODELAREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECWORCH AREA
GARAGE AREA DETACH
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A DWELLING UNITS:
ISA SECOND UNIT YES
SECOND STORY El YES
SKIING ADDED? []NO
ADDITION? [3NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
PLANNING ADPL / ❑NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES
EICHLER HOME? [3NO
RECEIVED BY:TOTAL
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VALUATION:
�'-
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Zdr 000_
13y my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the pnrperty owner's behalf. I have read this
application and the information I ha a vided 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 ding c tion. I authorize representatives of Cupertino
to enter the above -i
tified property for inspection purposes.
Signature of ApplicantlAgent
Date: )
SUPPLEMENTAL INFORMATION REQUIRED
PLAIN Cmcx TYPE
ROUTE% SLIP
�ornrrER
�IlNG PLAN RLrVMW
_ 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.
Cl EXPRESS
❑ PLANMG PLAN REVIKW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
11STANDARD
C1PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project
❑ LARGE
❑ nRs DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANTIARY SEWER DISTRICT
ubinittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_1011.doc revised 06/21/11
P
3 ITEMS OF 33
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32627037.10268
DATE ISSUED.......: 10/24/2011
RECEIPT #......... BS000015126
REFERENCE ID # ...: 11100125
SITE ADDRESS 10268 PARKWOOD DR
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OPERATOR: patg
COPY # : 1
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
24.00
652.00
0.00
652.00
----------
0.00
----------
TOTAL PERMIT
----------
655.00
----------
0.00
655.00
0.00