B-2017-0959CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0959
10124 PARKWOOD DR APT 8 CUPERTINO, CA 95014-1436 (326 27 036) THERMAL
MECHANICAL
SANTA CLARA, CA
95054
OWNER'S NAME: AVERY GLENBROOK LP
OWNER'S PHONE: 650-961-8330
LICENSED CONTRACTOR'S DECLARATION
r
License Class C-4. 10.20.36.38 Lic. #256057
Contractor THERMAL MECHANICAL Date 01/31/2018
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:
t. 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
�`_'
erformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance, as provided for by
tion 3700 of the Labor Code, for the performance of the work for which this
ilo ermit isissued.
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
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 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 with all non -point
source regulations per{ the Cupertino Municipal Code, Section 9.18.
6/22/2017
•. s• W
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. 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
DATE ISSUED: 06/22/2017
PHONE NO: (408) 988-8744
BUILDING PERMIT INFO:
X BLDG X ELECT X PLUMB
X MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
BLDG #20/UNIT #8; ADD (N) A/C; REPLACE FURNACE, SAME
LOCATION; (N) WASHER AND DRYER HOOK UPS; (N) ELECTRICAL
SERVICE (70 AMP); (N) GAS LINE FOR STOVE; (N) RECEPTACLE
OUTLETS; (N) LIGHT; (N) BATHROOM EXHAUST FANS.
Sq. Ft Floor Area: I Valuation: $20000.00
APN Number: Occupancy Type:
326 27 036
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: AbbyA• eLnde
Date: 06/22/2017
RE -ROOFS:
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.
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed Signature ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code). Date: 6/22/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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.
2. 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.
a. 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 become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
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 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 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 with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Sig
Date 6/22/2017
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date: 6/22/2017
CQNST CTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
PROJECT ADDRESS 10124 Parkwood DR, BLDG 20, Unit #8
CONSTRUCTION PERMIT APPLICATION
''
"OMM3UNITY DEVELOPMEN-1 DE=PARTMENT - BUILDING DIVISION
jj
10300 TORRE AVENUE • CLIPERTiNC, CA 950114-3255
(— —�
CUPERTINO
(408', 777-3228 • FAX (408) 777 33 3 • �
/� �.�.
❑ NEW CONSTRUCTION
GtJce6�
❑ ADDITION 0 ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 10124 Parkwood DR, BLDG 20, Unit #8
APN# `2 — 1-+
:J 03
OWNERNAME Avery Glenbrook LLC
PHONE 650-961-8330
E-MAIL avery@pacbell.netacbell.net
STREET ADDRESS
130 East Dana Street
, CITYSTATE, ZIP
Mt. View, CA 94041
FAX
650-961-0571
CONTACT NAME Rob Moyer
PHONE 408-593-8115
E-MAIL rmoyer@thermalmech.com
STREET ADDRESS 425 Aldo ave.
CITY, STATE, ZIP
Santa Clara, CA 95054
FAX 408-988-0233
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CK CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME Thermal Mechanical
LICENSE NUMBER 256057 I
CENSE TYPE
TCL-4,10,20.36,38
BUS. LIC # 299
COMPANY NAME Thermal Mechanical
E-MAIL rmoyer@thermalmech.com
FAX 408-988-0233
STREET ADDRESS 4255 Aldo ave.
CITY, STATE, ZIP Santa Clara, CA 95054
PHONE 408-988-8744
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
add new AC, replace furnace in same location, (N) washer/dryer 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
I
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 DECKIPORCH AREA
GARAGE AREA: LJ DETACH
[]ATTACH
I
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? []NO
ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY:
TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf I have read this
application and the information I have provided 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 to building construction. I authorize representatives of Cupertino to enter the above-identifiedpro erty for inspection purposes.
Signature of Applicant/Agent: Date: E?
SUPPLEMENT INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
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.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
El MAJOR
11 SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11