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12040027 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10203 PARKWOOD DR CONTRACTOR:STEVE PLFVANCIC PERMIT NO: 12040027 CONSTRUCTION OWNER'S NAME: AVERY GLENBROOK LP 528 S MATHILDA AVE STE 2 DATE ISSUED:04/05/2012 OWNER'S PHONE: 6509618330 SUNNYVALE.CA 94086 PHONE.NO:(408)806-9145 ❑ LICENSED CONTRACTOR'S DECLARATION F F F_ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.q MECH RESIDENTIAL COMMERCIAL Contractor. Date 1 hereby affirm that 1 am licensed under the provisions of&apter 9 JOB DESCRIPTION:APT -DECK RAILING AND POST REPLACEMENT (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penally 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.FI Floor Area: Valuation:$5000 1 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:32627037.10203 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 properly 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 aceme against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply �J) with all non-p inl source regulations per the Cupertino Municipal Code,Section Issued by: //U� f�N Date: 9.18, Signature Date RF:ROOFS: ❑ OWNER-RUILDER DECLARATION All roofs shall be inspected prior to any roofing material berg installed.If a roof is installed without fust obtaining an inspection,I agree to remove all new materials for 1 hereby affirm that 1 am exempt from the Contractor's License Law for ane Of inspection. the following two reasons: I,as owner of the properly,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) L as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec7044,Business&Professions Code). 1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 1 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 Cade,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(x)should 1 store or handle hazardous material. I have and will maintain Workers 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 Ouslity Management District 1 will permit is Issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which This permit is issued,I shall Health&Safety Code.Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Own rued agent: Compensation laws of Califomia. If,after making this certificate of exemption,I Dater 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 1 hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this pemtil 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 slate 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting 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 CONSTRUCTION PERMIT APPLICATION I Zvq 0<:�� a77COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)77-3228• FAX2fERATIONITI 333• buildinOno cupertino.ora ❑NEW CONSTRUCTION [:1 ADI AD ❑ REVISION/DEFERRED ORIGINAL PERhffTT# PROJECT ADDRESS C)2 ' - AP2 -7 , 7 , 0 Z T J 3. OWNER NAME vcn YGC J3�oiC CP 7 76 .0-961-2r MAvLys 44Al STREET ADDRESSCITY, ATI:ffi F i CONTACT NAMEONE SLC ✓lam CrUvrJctL O -S'O6- 7 41 ST[ r LQ-✓ ht a. I Gv STREET ADDRESS S. C741ATN n e A U P ❑OWNER ❑ OWNER-BURDEa ❑ OWNER AGENT 11 -GIMACTOR 13 CONTRACTOR 13CONTRACTOR AGENT ARCRTIECT C3ENGINEEt 11 DEVELOPER 1:1 TENANT CONTRACTORNAME `U I nGA �^ LICENSE NUMB I��--/6 9G LICENSE TYPE jZ BUS.LICA COMPANY NAME c' `- E-MAIL (( �UaZ751•' l e e >7 , a S e0 e� ir1a, �rCv»1 STREET ADDRESSS['AT�IIP ONE a S� vu le L u 6- S ARCHITECT/FNOINEER NAME a J .iL LICENSENUMBER BUS.LIC4 COMPANY NAME (� Y` E-MAIL FAX STREET ADDRESS CITY.STATE.ZIP PHONE OFSCRIPTION OF WORK If JA 9- EXISTING USE PROPOSFDUSE CONSTiLTYPE NSTOIUES USE TYPE OCC. SQFT. VALUATION(S) =G NEW FLOOR DEMO TOTAL771-47-7 ^ ^D AREA RATHROOM AREA AREA OTHER NET AREA •fS'G� l� V_/ - REMODEL NEMO REMODEL AREA REMODp.AREA RFMDOEZ AREA PORCH AREA I DECK AREA MTALDECK/PORCHARFJ, I GARAGE AREA: DETACH ATTACH a DWEll.tNG UNDS: ISASECOtNDUNIT 0 YES SICOND STORY YES - BEING ADDED? []NO ADDITION! ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑TE4 RECEIVED BY: I TOTAL VALUATION:/ PLANNDNGAPPLS ❑NO PLANNING APPROVALUTTFR. IICTIIBR BOMB? [3 NO By my signature below,I certify to each of die follotvmg: I am the property owner or authorized agent to act an the pryperty owaces behalf. I have read this application and the information I ha a sided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable taco] urdmancm and state laws relating oting 'ore I authorize representatives of Cupertino to enter the above-identifled property for inspection purposes. Signature of Applicant/Agent: Dare: C7— — y �� SUPPLEMENTAL INFORMATION REQUnU9 PEAN CHBCKTYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for o� BDaDmc PLAN Rzvaw existing building(s). Denalition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW —Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD CIPUBLIC WORKS Form if any Hazardous Materials are being used as part of this project ❑ LARGO ❑ PIRR nor _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY sawea DrsTRler submittal of Building Permit application. ❑ INVIRONMIMIAL HEALTH 81dgApp_20/I.doc revised 06/21/11