B-2016-3231 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3231
10253 PARKWOOD DR APT 3 CUPERTINO,CA(326 27 037) THERMAL
MECHANICAL
SANTA CLARA,CA '
95054
OWNER'S NAME: AVERY GLENBROOK LP DATE ISSUED:12/09/2016
OWNER'S PHONE:650-961-8330 PHONE NO:(408)988-8744
LICENSED CONT CTOR' D C A ATION BUILDING PERMIT INFO:
License Class C-4.10.20,36.38 Lie.#256057 X BLDG X ELECT X PLUMB
Contractor THERMAL MECHANICAL Date 01/31/2018
X MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
BLDG 43/UNIT 3;ADD(N)A/C;REPLACE FURNACE,SAME
I hereby affirm under penalty of perjury one of the following two d"eclarations: LOCATION;(N)WASHER AND DRYER HOOK UPS;(N)ELECTRICAL
i. I have and will maintain a certificate of consent to self-insure for Worker's SERVICE(70 AMP);(N)GAS LINE FOR STOVE;(N)9 RECEPTACLE
Compensation,as provided for by Section 3700 of the Labor Code,for the OUTLETS;(N)1 LIGHT;'(N)BATHROOM EXHAUST FAN
/performance of the work for which this permit is issued.
pi.' 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. Sq.Ft Floor Area: Valuation:$20000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 326 27 037
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. 'WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino,Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ' Date 12/9/2016 Issued by:Abb A made ,
Date: 12/09/2016
OWNER-B DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be ins.ected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature ofApplican:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:12/9/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROO COVERINGS TO BE CLASS"A"OR BETTER
1. 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. H ARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se ions 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. r' I/
Owner or authorized agent: _.,,-
APPLICANT
APPLICANT CERTIFICATION Date: 12/9/2016 .„/"""
I certify that I have read this application and state that the above information is EONS UGTION LENDING AGENCY
correct.I agree to comply with all'city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 12/9/2016 Professional
CONSTRUCTION PERMIT APPLICATI• N
COMMUNITY DEVELOPMENT DEPARTMENT•BU„ ,.. ,
ILDING D VISIONB
w�I' 10300 TORRE AVENUE•GUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333 O.
buildinq@cupertino.orq 7_6, /
CUPERTIN
❑NEW CONSTRUCTION ❑ ADDITION I o
❑Q ALTERATION/TI ❑ REVISION/DE'E� ORIGINAL PERMIT#
PROJECT ADDRESS 10253 Packwood DR, BLDG 43, Unit#3 AFN# Z'' ' Z— "d ? ?--
OWNER NAME Avery Glenbrook LLC PHONE E-MAIL
650-961-8330 avery@pacbell.net
STREET ADDRESS 130 East Dana Street CITY,STATE,ZIP
Mt. View, CA'%4041 FAX
650-961-0571
CONTACT NAME Rob Moyer PHONE 408-593-8115 E- Lrmoyer@thermalmech.com
STREET ADDRESS 425 Aldo ave. CITY,STATE,ZIP FAX 408-988-0233
Santa Clara, •aA 95054
❑OWNER 0'OWNER-BUILDER 0�OWNER AGENT IX CONTRACTOR ❑CONTRACTOR AGENT 0 A'CIIITECT ENGINEER ❑' DEVELOPER ❑ TENANT
CONTRACTORNAMEThermal Mechanical LICENSE NUMBER 256057 LICNSETYPE BUS.LIC# 299 -
C 10,20.36,38
COMPANY NAME Thermal Mechanical
ELrmoyer@thermalmec .co
FAX 408-988-0233
STREETADDRESS 425 Aldo ave. CITY,STATE,ZIP Santa Clara, IA 95054 PHONE
408-988-8744
ARCHITECT/ENGINEERNRME LICENSE NUMBER BUS.LIC
COMPANY NAME E-MAIL ' FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK_ _ r.
add new AC, replace furnace in same location, (N)washer/drye hook ups, (N)electrical panel(70 AMP),
(N)gas line for stove, (N)electrical outlets,(N)light, (N) bathroom exhaust fan
EXISTING USE PROPOSED USE. CONSTR.TYPE #STORIES - - - -
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL - -
- AREA AREA AREA - NET AREA
BATHROOM KITCHEN .OTHER - - - - - -
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑DETACH
❑.ATTACH
#DWELLING UNITS: ISA SECOND UNIT ❑YES SECOND STORY ENO
BEINGADDED? ❑NO ADDITION? "❑NO _41
PRE-APPLICATION
DYES IF YES,PROVIDE COPY OF IS THE BLDG AN' ❑YES RT#C ' alrlir 77 TOTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICIILER HOMET ❑NO :9;,'1_ ,- )
77,6..
By my signature below,I certify to each of the following: I am the property owner or autho ed age act•"+i e propeMi rty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and veri is ccurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I.uthorize representatives of Cupertino to enter the above-idea for inspection purposes.
Signature of Applicant/Agent: _,....„,,,,..._,„,r-- Date: j/
r�
SUPPLEME
Al'
L INFORMATION REQUIRED pLp, Apt
New SFD or Mul'dwellings: Apply for demolition permit for
{IVER TEIE C4I NT FR BL7ILITTNG I I �SIE V3>iI
existing building(s). Demolition permit is requtred prior to issuance of building ;-,
permit for new building. L; >txPiutsii: IINc1LANiti IEw
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDAriAttor,RD Q PtI&LIC iv tCa -
form if any Hazardous Materials are being used as part of this project.
Copy of Planning Approval Letter or Meeting with Planning prior to
D mraaoi;' 0nrrrY saERrtsr> c
submittal of Building Permit application.
Y t�YYRON ENTAI EIEALTU
B1dgApp_2011.doc revised 06/21/11