10050102 REV1 CITY OF CUPERTINO BUILDING PERMIT REVISION#�-1
BUILDING ADDRESS: 10195 PARKWOOD DR UNIT 4 CONTRACTOR:AVERY DA
GI,ENBROOK LP
VNER'S NAME: AVERY GLENBROOK LP 130 E DANA ST DATE ISSUED:05/12/2010
OWNER'S PHONE: 4082045367 MOUNTAIN VIEW, CA 94041 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONf—
BL ILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
JO B DESCRIPTION: REPAIR R1 COMPLEX FROM FIRE DAMAGE TO
I hereby affirm that I am licensed under the provisions of Chapter 9
FR kMING,ELECTRICAL,ROOF RAFTERS&ROOF
(commencing with Section 7000)of Division 3 of the Business&Professions CC VERING;800SQ.RE-ROOF 32SQ&DOES HV STRUCTURAL
Code and that my license is in full force and effect. 5/23/10-REVISION#I-REVISE ROOF FRAMING
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:$40000
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 Al N Number:32627037.10195.4 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 toienter
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 Is:ued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section _
9.18.
RE-ROOFS:
;nature Date Al roofs shall be inspected prior to any roofing material being installed.If a roof is
in:talled 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 Signature of Applicant: Date:
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 comp s tion,
will do the work,and the structure is not intended or offered for sale(Sec.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed co ctors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I t ave read the hazardous materials requirements under Chapter 6.95 of the
Cs lifornia 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: Hi alth&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 a pment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the BA Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the upertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided fory th,:Health&Safety Code,Sec'a s 2 X33,an 4.
Section 3700 of the Labor Code,for the performance of the work for whit s �'"� r r
permit is issued. Owner or authorized age Date: U
I certify that in the performance of the work for which this permit is issue shall
not employ any person in any manner so as to become subject to the Wo er'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 Lc nder'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
building construction,and hereby authorize representatives of this city to enter
on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keeph less the City of Cupertino against liabilities,judgments,
costs,and expenses is ay true against said City in consequence of the I L nderstand my plans shall be used as public records.
granting of this pe it., .dd' ' ally;"the.4pplicant understands and will comply
with all non-poi 5o e rtations per th Cupertino Municipal Code,Section Li sensed Professional
9.18.
Signature—�� Date Zt 1r5