12010029 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10214 PARKWOOD DR CONTRACTOR:STEVE PLEVANCIC PERMIT NO: 12010029
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED:01/04/2012
C 'ER'S PHONE: 6509618330 SUNNYVALE,CA 94086 PHONE NO:(408)806-9145
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
/
License Class Lic.# `� /r
6 7
MECH RESIDENTIAL COMMERCIAL
Contractor,o tJ G (f7,y�ate
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I hereby affirm that I am licensed under the provisions of C apter 9 JOB DESCRIPTION:WINDOW REPLACEMENT(26)
(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:
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. Sq.Ft Floor Area: Valuation:$20000
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. APN Number:32627037.10214 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)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 ermit. Additionally,the applicant understands and will comply
with all non-poi source reg tions per the Cupertino Municipal ode, ection Issued by Date:
9.18.
Signature Date
RE-ROOFS:
L OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and 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
construct the project(Sec.7044,Business&Professions Code).
I hereby 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 Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 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(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
In tai compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health afety C ectlons 25505,25533,and 25 34.
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 OwnM u ize ent:
Compensation laws of California. If,after making this certificate of exemption,I Date: I y
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
inciPmnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
&_...mg of this 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
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10214 parkwood dr. DATE: 01/04/2012 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$20,000
RIPERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex [PERMIT
ENTAMATION 1GENRES
USE: TYPE:
WORK window replacement 26.
SCOPE
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelindina information available and are only an estimat4 Contact the De t or addn'1 info.
FEE ITEMS (Fee Resohition I1-053Eff. '1.-11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Window/Sliding Glass Door
Suppl.PC Fee: (F) Reg. Q OT 0.0 hrs $0.00 $782.00 IWINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Supp/.Insp. Fee Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? 0 Yes E) No $0.00 G
Advanced Piannina Fee: $0.00 Select a Non-Residential G
Building or Structure 0
i
Strong Motion Fee: IBSE1SN11CR $2.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $3.00 $782.00 TOTAL FEES $785.00
Revised: 1/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
;U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: ,^ PERMIT# nG'
OWNER'S NAME: 2� PHONE#
GENERAL CONTRACTO p_va vZ a BUSINESS LICENSE#
ADDRESS:,-W- = CITY/ZIPCODE w h ,,
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SU CONTRACTORS HAVE OBTAINED A CITY F UPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting
Linoleum/Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
1:2-0100 -01
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408�77 -3333• building(a7cupertino.orq
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION
/DEFERRED ORIGINAL PERMIT#
PROIECT ADDRESS !f' /„ APN# / - �. �7. 02
OWNER NAME /Cv� / y p PHONE`
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STREET 3 O ADDRESS i �/P. s'{ C1TY P � � 1
CONTACT NAME _ E
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STREET ADDRESS 'A4
1 CI1 Y,STATE ZIP /� F
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT WC-ONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMELICENSE NUMB / LICENSE TYPE }3 BUS.LIC#
COMPANY NAME ) '[�g"75- ^
Q� n i vh Tl� ESS Qu EV F
STREET ADDRESS CITY,STATE,ZIP P ONE
ARCHITECUENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME f v YT E-MAJL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK Vd
ouJ r P,414C-e -
EXISTING USE PROPOSED USE CONSTR TYPE #STORRIES
USE TYPE OCC. SQ_FT. VALUATION(5)
EXLSTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NEI'AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKIPORCH AREA I GARAGE AREALJ DETACH
❑ATTACH
#DWELLING UNITS: LSA SECOND UNIT OYES SECOND STORY OYES
BEING ADDED? []NO ADDITION? ONO
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 pr•nperty owner's behalf. I have read this
application and the information I ha a rovided 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 u ding c tion I authorize representatives of Cupertino to cater the above-identified property for inspection purposes.
Signature ofApplicant/Agent Date:
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE R0UnNG SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for 14__0�-TXE_COUN7 R 13unmiNG PLAN RLNTEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ MRESs ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ MLIC WORKS
To—rm.if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DUT
_Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR ❑ sANrraRY SEWER DISTRICT
ibmittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 Ldoc revised 06/21/11