13100018 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21316 GLEN PL CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 13100018
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED:10/01/2013
OWNER'S PHONE: 6509618330 SUNNYVALE,CA 94086 PHONE NO:(408)806-9145
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class Lic.# " BLDG 13-REMOVE AND REPLACE 40 WINDOWS TO
MEET
Contractor Date O P1 ( EGRESS IN BEDROOMS
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. Sq.Ft Floor Area: Valuation:$20000
I have and will main in Worker's Compensation Insurance,as provided for by
Section 3700 of abor Code,for the performance of the work for which this APN Number:32627036.21316 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 1 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS M 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 �U /3
Issued by: Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municip Code,Section
9.18.
f RE-ROOFS:
Signat D ( 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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California 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: Health&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 equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance ith the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety C c' s 2 505,25533,and 25534. /
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorize agent: Date/O G r
1(3
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 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 Lender'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
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CONSTRUCTION PERMIT APPLICATION \�
is COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION +�
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �
(408)777-3228• FAX(408)777-3333•build nrti
cz peno.orq `
CUPERTINO
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATIO ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROMCT ADDRESS^01,3 I� I�� APN# 32� 2, -7 C3 . 2131&
OWNER NAME��/[�-f� /L N PHONE E-MAIL ,^vL �s7�vLC l c�
J- P
STREET ADDRESS CITY,/70
ITY. Te r1 a
CONTACT NAME
7 IL eUA�GI rL t= LL
EET Cq MH-
STRADDRESS • 4-1 CITY. �A U F
r
❑OWNER ❑ OWNER-BUn.DER ❑ OWNER AGENT IYC0NTRAcr0R ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME ' va�C(�^ LICENSE NUMB17 t. 5r LICENSE TYPE 45 BUS.LIC#
COMANMEQ U E-MAIL u F
44 k6o
Ya vs ,e(,e
E
.Cv n1
STREET ADDRESS CITY,STATE ZIP P ONE
S of '? a S vu le,
a G
ARCHPCECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK QA ,^^ j, k4LUtte_ r` ' of i
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
1Z!-1 USE TYPE OCC. SQ.FI. VALUATION(5)
EXLSTG NEW FLOOR 7DEMO TOTAL
AREA AREA AREA NET AREA -
BATHROOM KITCHEN OTHER
REMODELAREA REMODELAREA REMODEL AREA
PORCH AREA DECK AREA TOTAL.DECK/PORCH AREA I GARAGE AREA Ll DETACH
[]ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY []YES
BEING ADDED? ONO ADDITION? []NO
PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS TBE BLDG AN ❑YES RETOTAL VALUATION:_
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICELER HOME? [3NO
Z'c��
By my signature below,I certify to each of the following I am the property owner or autho ' d ent to act on the property owner's behalf. I have read this
application and the information I ha a rovided is correct. I have read the Description of W d 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-' fied property for inspection purposes.
Signature of Applicant/Agent ` Date; Q
SUPPLEMENTAL INFORMATION REQUIRED PLAffj=xCKTYPZ ROUTRiG SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for C1 OVER-THE-COUNTER ❑ sUII DING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN RrUW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11rm
sTAARD 11 PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. 11 LARGE
❑ FntE IFFY
_Copy of Planning Approval Letter or Meeting with Planning prior to 11 MAJOR ElsANrrARY SEWER DLSTTucr
submittal of Building Permit application.
❑ ENVMON.�NTAL HEALTH
BldgApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUJ,,DING DIVISION
ADDRESS: 21316 Glen PI W,--: 10/01/2013 REVIEWED BY: MENDEZ
APN: BP#: Ar *VALUATION: 1$20,000
*PERMIT TYPE: Building Permit PLAN C. SCK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
wORK bld 13- remove and replaceA windows
SCOPE
s�
Check Pt wib. Narz Oteck I>lc:r.'. filar z C;r<:r:k
t7rt:it.I'r rppAig J'ee
i nF:Fi. III.Yi 1. f"t c': =iTZ1,�22.,.x'..5 €.'a. L.?"`."E:, hs])? F£:+`_'.'
NOTE.This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn I info,
FEE ITEMS (Fee Resolution 11-053 E . 7/�1/Q FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 40 # Window/Sliding Glass Door
Suppl. PC Fee: (j) Reg. 0 OT 0.0 I hrs $0.00 $974.00 1WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:(F) Reg. ® OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Work Without Permit? 0 Yes (j) No $0.00 0
Advanced Planning Fee. $0.00 Select a Non-Residential E)
`
l�t"Ltt%£�E.
y } Building or Structure 0
L�t9F'x?te7€"12ias`7£3tt E'M'S; �
Strong Motion Fee: IBSEISMICR $2.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
,
y
' $3.00 $974.00 . TOTAL FEE: $977.00
Revised: 08/01/2013