B-2017-1178CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1178
10234 PAR,KWQOD DR APT 3 CUPERTINO, CA 95014-1528 (326 27 037)
THERMAL
MECHANICAL
SANTA CLARA, CA
95054
OWNER'S NAME. AVERY GLENBROOK LP
DATE ISSUED: 07/26/2017
OWNER'S PHONE. 650-961-8330
PHONE NO: (408) 988-8744
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO'
License Class CA. C -1 0'C -36-C-38 Lic. #256057
Contractor THERMAL MECHANICAL Date 01/31/2018
X BLDG X ELECT X PLUMB
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 #62/UNIT#3, ADD (N) A/C; REPLACE FURNACE, SAME
I hereby affirm under penalty of perjury, one of the following two declarations:
LOCATION, (N) WASHER AND DRYER HOOK UPS; (1) ELECTRICAL
1. I have and will maintain a certificate of consent to self -insure for Worker's
SERVICE (70 AMP); (N) GAS LINE FOR STOVE, (l) RECEPTACLE
Compensation, as provided for by Section 3700 of the Labor Code, for the
OUTLETS, (N) LIGHT, (I) BATHROOM EXHAUST FANS,
performance of the k for which this permit is issued.
ve and will mainr's Compensation Insurance, as provided for by
�:brke
Section 3700 of the Code, for theperformance of the work for which this
permit is issued.
Sq. Ft Floor Area: Valuation: $20.000.00
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
326 27 037
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
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 compjy with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION
Signature e /
Issued by Abby __A _Ay nde
Date: 07/26/2017
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
FR ROOFS'
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
I, as owner of the or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
i. property
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 of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 7/26/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
have Worker's Compensation Insurance, as provided for by
I have read the hazardous requirements under Chapter of the
2. I and will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
34.
y Codmaterie, 25533, and ter 9.1 I will
California Health &Safety Code, Sections Municipal
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
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, Sectio 5, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
or
be deemed revoked.
O; -n re authorized agent:
Date: 7/26/2017
APPLICANT CERTIFICAIION
I certify that I have read this application and state that the above information is
�ONSTRUC ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 7/26/2017
professional
ACU PSRTI INl t
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)'777-3228 • FAX (408) 777-3333 • building(ocupertino.org
NEW CONSTRUCTION ❑ ADDITION Q ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 10234 Packwood DR, BLDG 62, Unit #3 APN# 1
owNERNAME Aver Glenbrook'LLC PHONE E-MAIL avery@pacbell.net
Avery 650-961-8330 rY@P
STREET ADDRESS 130 East Dana Street CITY, STATE' ZIP Mt. View, CA 94041 FAX
650-9.61-0571
CONTACT NAME Rob Moyer PHONE 408-593-8115 E-MAIL. rmoyer@thermalmech.com
STREET ADDRESS CITY, STATE,.. ZIP FAX 408-988-0233
425 Aldo ave, Santa Clara, CA 95054
❑' OWNER ❑ OWNER -BUILDER OWNERAGENT I CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT El ENGINEER ❑ DEVELOPER. ❑: TENANT
CONTRACTOR NAME LICENSE.NUMBER 256057 LICENSE TYPE BUS. LIC # 299.
Thermal Mechanical C-4,10,20,36,38
coMPANYNAME Thermal Mechanical E-MAILrmoyer@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
I STREET ADDRESS
E-MAIL I FAX
CITY, STATE, ZIP I PHONE
DESCRIPTION oaWORK 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
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 GARAGEAREA: DETACH
❑ ATTACH
#DWELLING UNITS: IS ASECOND UNIT _❑YES SECONDSTORY []YES
BEING ADDED? ❑NO ADDITION? []NO
PRE -APPLICATION r1YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑. YES GEI D $ TOTAL VALUATION:
PLANNING APPL # NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NOZVI9 OW
,(�
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the p aperty 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 buildin s f n. I authorize representatives of Cupertino to enter the above-identifiedproperty for inspection purposes.
Signature of Applicant/Agent: r Date:
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.
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
fo_rm if any Hazardous Materials are being used as part of this project.
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
BldgApp 2011,doc revised 06121/11