12030021 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10195PARKWOOD DR CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 12030021
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED:03/052012
OWNER'S PHONE: 6509618330 SUNNYVALE.CA 94086 PHONE NO:4408)8069145
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I- ELECT r PLUMB r
License Class Li,.N
h1ECH r RESIDENTIAL r COMMERCIAL
Commaor Oq,l'he..L i Date
1 hereby affirm that 1 am licensed under the provisions of Chapter JOB DESCRIPTION:RELACE 3 WINDOWS AT EXISTING APT.COMPLEX
(cunuuencing with Section 7010)of Division 3 of the Business&Professions
Code and(lint my license is in full force and effect.
1 hereb' affirm under penalt)'of Perjury one of the following two declarations:
I have and will maintain a cerrif:ate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Glide,for rhe
pehfomuance of the work for which this permit is issued.
(have rind will maintain Worker's Compensation Insurance,as provided for by S4 Ft Fluor Area: Valuation:STOW
Section 3700 of die Labor Code.for the performance of die work for which this
Permit is issued. AI'N Number:32627037.10195 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application mid stare dim(Phe above infomn[ion is
correct.I agree to comply with all city and county ordinances mid state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building constmction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (Wc)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. .Additionally,the applicant understands mid will comply
with all non-pou source regulatims per the Cupertino Municipal Code,Section Issued b Date:
9.18.
Signature Date �L
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior many roofing material heng installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that 1 am exempt front the Contractor's License Law for one of inspection
Ilse fallowllhg two relu mus:
1,as owner of the property,or nay employees with wages as their sole compensation. Signature of Appliarnt Date:
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&- Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
consmnn the project(Sec.7044,Business&Professions Code).
I het thy affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Cemihcate of Consent to self-insure for Worker's California Health R Safety Code,Sections 25505.25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code.Section 25532(e)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally.should 1 use equipment or devices which emit hazardous air
Section 3700 of the labor Code,for the Performance of the work for which this conmminants as defined by the flay Area Air Quality Managenment District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Sections 25-505.25533.and 25534.
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 Osc a lhmr'zed agent:
Compensation paws of California. If,after making this certificate of exemption,l Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
fittthwi(h comply with such provisions or this permit shall be deemed revoked. CONSTRl1fT10N LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of mork's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097.Or C.)
I certify that I have read this application and state toot the above information is Lender's Na nate
correct.I agree to comply with all city and county ordinances and state paws relating
to building construction,mid hereby authorize representatives of this city to enter Lender's Address
upon tie above mentioned property for inspection purposes.(We)agree to save
indemnity and keep hamiless the City of Cupertino against liabilities.judgments,
costs,anti expenses which may acme against said City in consequence of the ARCHITECT'S DECLARATION
granting of(his permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10195PARKWOOD DR CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 12030021
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED:03/052012
OWNER'S PHONE: 6509618330 SUNNYVALE.CA 94086 PHONE NO:4408)8069145
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I- ELECT r PLUMB r
License Class Li,.N
h1ECH r RESIDENTIAL r COMMERCIAL
Commaor Oq,l'he..L i Date
1 hereby affirm that 1 am licensed under the provisions of Chapter JOB DESCRIPTION:RELACE 3 WINDOWS AT EXISTING APT.COMPLEX
(cunuuencing with Section 7010)of Division 3 of the Business&Professions
Code and(lint my license is in full force and effect.
1 hereb' affirm under penalt)'of Perjury one of the following two declarations:
I have and will maintain a cerrif:ate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Glide,for rhe
pehfomuance of the work for which this permit is issued.
(have rind will maintain Worker's Compensation Insurance,as provided for by S4 Ft Fluor Area: Valuation:STOW
Section 3700 of die Labor Code.for the performance of die work for which this
Permit is issued. AI'N Number:32627037.10195 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application mid stare dim(Phe above infomn[ion is
correct.I agree to comply with all city and county ordinances mid state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building constmction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (Wc)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. .Additionally,the applicant understands mid will comply
with all non-pou source regulatims per the Cupertino Municipal Code,Section Issued b Date:
9.18.
Signature Date �L
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior many roofing material heng installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that 1 am exempt front the Contractor's License Law for one of inspection
Ilse fallowllhg two relu mus:
1,as owner of the property,or nay employees with wages as their sole compensation. Signature of Appliarnt Date:
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&- Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
consmnn the project(Sec.7044,Business&Professions Code).
I het thy affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Cemihcate of Consent to self-insure for Worker's California Health R Safety Code,Sections 25505.25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code.Section 25532(e)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally.should 1 use equipment or devices which emit hazardous air
Section 3700 of the labor Code,for the Performance of the work for which this conmminants as defined by the flay Area Air Quality Managenment District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Sections 25-505.25533.and 25534.
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 Osc a lhmr'zed agent:
Compensation paws of California. If,after making this certificate of exemption,l Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
fittthwi(h comply with such provisions or this permit shall be deemed revoked. CONSTRl1fT10N LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of mork's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097.Or C.)
I certify that I have read this application and state toot the above information is Lender's Na nate
correct.I agree to comply with all city and county ordinances and state paws relating
to building construction,mid hereby authorize representatives of this city to enter Lender's Address
upon tie above mentioned property for inspection purposes.(We)agree to save
indemnity and keep hamiless the City of Cupertino against liabilities.judgments,
costs,anti expenses which may acme against said City in consequence of the ARCHITECT'S DECLARATION
granting of(his permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date