B-2017-1153CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1153
10255 PARKWOOA DRAFT 3 CUPERTINQ, CA 95014-1467 (326 27 036) THERMAL
OWNER'S NAME: AVERY GLENBROOK LP
OWNER'S PHONE: 650-961-8330
LICENSED COMRACTOR'S DECLARATION
License Class C-4, C -1 0:C -36-C-38 Lic. #256057
Contractor THERMAL MECHANICAL Date 01/31/2018
hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
'ith Section 7000) of Division 3 of the Business & Professions Code and that my
cense is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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
4ha
rmance of the work for which this permit is issued.
ve 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
permit is issued.
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.
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. 1, 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) '
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I, hereby affirm under penalty of perjury one of the following three declarations:
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.
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.
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 v
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.
Signature Date 7126/2017
SANTA CLARA, CA
95054
ISSUED: 07/26/2017
PHONE NO: (408) 988-8744
BUILDING PERMIT INFO -
BLDG X ELECT X_ PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION
BLDG 42/UNIT 3, ADD (I) A/C; REPLACE FURNACE, SAME
LOCATION, N WASHER AND DRYER HOOK UPS, (I) ELECTRICAL
SERVICE (70 AMP); (N) GAS LINE FOR STOVE, (I) RECEPTACLE
OUTLETS, (I) LIGHT, (I) BATHROOM EXHAUST FAN
Sq. Ft Floor Area: I Valuation: $20000.00
"N 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.
by Abby Ayende
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.
Signature of Applicant:
Date: 1(26/2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BE
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: 7126/2017000
CO N LENDING AGOINCY
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
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(d-)cugertino.or-q
B
M _zn 1 -7 -
❑ NEW CONSTRUCTION ❑ ADDITION ❑X ALTERATION/ TI ❑ REVISION / DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS 10255 Parkwood DR, BLDG 42, Unit #3 'FN#(� ®Z7 �? 2
OWNER NAME - PHONE. E-MAIL. .
Avery Glenbrook LLC 650-961-8330 avery@pacbell.net
STREET ADDRESS 130 East Dana CITY, STATE, FAX
a Street Mt. View, CA 94041 650-961-0571
CONTACT NAME PHONE E-MAIL
-
Rob Moyer 408-593-8115 rmoyer@thermalmech.com
STREET ADDRESS CITY, STATE, ZIP FAX 408-988-0233
425 Aldo ave.: Santa Clara, CA 95054
❑ OWNER ❑ OWNER -BUILDER D OWNER AGENT IX CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER 11 DEVELOPER ❑ TENANT
CONTRACTORNAMEThermal Mechanic aI LICENSE NUMBER 256057 LICENSE TYPE BUS. LIC# 299
C-4,10,20,36,38
COMPANYNAME Thermal Mechanical E-MAILrmoyer@thermalmech.com FAX 408-988-0233
STREETADDRESS 425 Aldo ave. CITY, STATE, ZIP Santa Clara, CA 95054 PHONE
408-988-8744
ARCHITECT/ENGINEER NAME LICENSE NUMBER - BUS. LIC #
COMPANYNAME E-MAIL. - FAX
STREET ADDRESS CITY, STATE, ZIP PHONE -
DESCRIPTION OF WORK
add new At, 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
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: 0 DETACH
❑ ATTACH
i
#DWELLINGUNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEINGADDED? ❑NO ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES TI $y; „ TO'I;AL VALUATION:
PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER EICHLERHOME? ❑NO
m w,
By my signature below, I certify to each of the following: I am the property owner or authorized agent to let on th4 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-identi d property for inspection purposes.
Signature of Applicant/Agent: 11 Date:
N FORMATION REQU PLAN
SUPPLEMENTAL, ��oz��T�PI'E � IzguTING-<sLlr
New SFD or Multifamily dwellings: Apply for demolition permit for OVTRR
UNT
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. PLANNINIxPLAiV tlR i
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure L� AN'iIARA PUBLIC ops
form if any Hazardous Materials are being used as part of this project.
�ARGti = Q `>c1IIi1E1��I"�
_ Copy of Planning Approval Letter or Meeting with Planning prior to
NIATD �• �i�L'SERDISTRICx .
submittal of Building Permit application,
„ N.VII#(1NNi NTAT HEA TR,
BldgApp_2011.doc revised 06121111