10050102 CITY OF CUPERTINO BUILDING PERMIT
WILDING ADDRESS: 10194 PARKWOOD DR APT 4 CONTRACTOR:AVERY GLENBROOK LP PERMIT NO: 10050102
)V'vFR'S NAME: AVERY GLENBROOK LP 130 E DANA ST DATE ISSUED:05/12/2010
T 2'S PHONE: 4082045367 MOUNT,,IN VIEW,CA 94041 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
-icense Class Lic.# MECH F RESIDENTIAL f— COMMERCIAL
contractor Date
JOB DESCRIPTION:REPAIR RI COMPLEX FROM FIRE DAMAGE TO
[hereby affirm that I am licensed under the provisions of Chapter 9
FRAMING,ELECTRICAL,ROOF RAFTERS&ROOF
(commencing with Section 7000)of Division 3 of the Business&Professions COVERD G;800SQ.RE-ROOF 32SQ&DOES HV STRUCTURAL
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 Sq.Ft Fl)or Area: Valuation:$40000
permit is issued.
APPLICANT CERTIFICATION APN Nu nber:32627037.10194.4 Occupancy Type:
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 PE R.MIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WLTHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 1811 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date
/ OWNER-BUILDER DECLARATION RE-ROOFS:
,teby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspectic n.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Signatur
Business&Professions Code) ;of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additio pally,should I use equipment or devices which emit hazardous air
permit is issued. contain nants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health Sc SaMty Co ,Sections 25505,25533,and 25534.
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
42 r ID
Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereb) affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inpection purposes.(We)agree to save
it rify and keep harmless the,Citypfeupertino against liabilities,judgments, Lender's Address
and expenses whicVmay accju.e against said City in consequence of the
.anting of this permit>-Ad tionallq;the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source a lations per the Cupertino Municipal Code,Section
9.18. ,:' I under:tand my plans shall be used as public records.
-
Signature � �2 O Licensi d Professional
--�'-
Z`/