B-2017-0953CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
21337 GLEN PL APT 5 CUPERTINO, CA (326 27 036)
CONTRACTOR:
THERMAL
PERMIT NO: B-2017-0953
MECHANICAL
SANTA CLARA, CA
95054
OWNER'S NAME: AVERY GLENBROOK LP
DATE ISSUED: 06/22/2017
OWNER'S PHONE: 650-961-8330
PHONE NO: (408) 988-8744
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-4:10:20:36.38 Lic. #256057
Contractor THERMAL MECHANICAL Date 01/31/2018
X BLDG X ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
X MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations:
BLDG #41/UNIT #5; ADD (N) A/C; REPLACE FURNACE, SAME
i. I have and will maintain a certificate of consent to self -insure for Worker's
LOCATION; (N) WASHER AND DRYER HOOK UPS; (N) ELECTRICAL
SERVICE (70 AMP); (N) GAS LINE FOR STOVE; (N) RECEPTACLE
Compensation, as provided for by Section 3700 of the Labor Code, for the
OUTLETS; (N) LIGHT; (N) BATHROOM EXHAUST FANS.
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
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
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
326 27 036
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 this permit.
Additionally, the applicant understands and will comply with all ll non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature_ 6/22/2017
Issued by: Abby Ayende
OWN .R -B I D R DECLARATION
Date: 06/22/2017
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 inspected prior to any roofing material being installed. If a roof is
1. I, as ownei"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 stricture 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 of Applicant:
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:
t. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
HAZARDOUS 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
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
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
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 255-1 , and 5534.
Labor Code, I must forthwith comply with such provisions or this permit shall
f
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 6/22/2017
1 certify that I have read this application and state that the above information is
CONSTRUCTION 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. 1
understand my plans shall be used as public records.
Signature Date 6/22/2017
Licensed
Professional
I
UPERT1N0
❑ NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELO 01- i11 ! DEPARTVEry i BUILDING Dal ISJION
1
0300
1 C)FRF AVENUE • C' +F rR? INt7 C,1 95014-32"'55
❑ ADDITION ❑X ALTERATION /TI ❑ REVISION / DEFE
BldgApp_2011.doc revised 06/21/11
RRED "U"11VHL ruh-M11 17
PROJECT ADDRESS 21337 Glen Place, BLDG 41, Unit #5
APN# ` p' �. �
cam/lJ
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 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 IX CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
Thermal Mechanical
LICENSE NUMBER
256057
LICENSE TYPE
BUS. LIC #
299
C-4 10 20 36 38
COMPANY NAME Thermal Mechanical
E-MAIL
y °�
rmo er thermalmech.com
FAx 408-988-0233
STREET ADDRESS 425 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: 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
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
RECEIVED BY:
TOTAL VALUATION:
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 1 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 build i ns ction. I au horize representatives of Cupertino to enter the above-idenf led roperty r inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL fNFORMATION REQWRED
PLAN CHECK TYPE
ROUTING SLIP
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
1:1 OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
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.
❑ MAJOR
❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11