13060107CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10254 PARKWOOD DR
CONTRACTOR: STEVE PLEVANCIC
PERMIT NO: 13060107
CONSTRUCTION
OWNER'S NAME: AVERY GLENBROOK LP
528 S MATHILDA AVE STE 2
DATE ISSUED: 06/13/2013
OWNER'S PHONE:: 6509618330
SUNNYVALE, CA 94086
PHONE NO: (408) 806-9145
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL
BLDG #2- REMOVE AND REPLACE 26 WINDOWS LIKE
License Class Lic. #
FOR
Contractor llUci Date %
LIKE
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.
Thereby 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
APN Number: 32627037.10254
Occupancy Type:
Section 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
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN/"O DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DA F M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: Date: /3• ��
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.
RE -ROOFS:
Signature Date Odl3lf3
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.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the. Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 225533, 5534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
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
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with ail non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTIINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildingQcupertino.orcl $
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❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESSAPN
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CONTACT NAME
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❑ OWNER ❑ OwNER-BUILDER ❑ OWNER AGENT WC-0NTRAcrOR ❑ CONTRACfORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
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LICENSE NUMB
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LICENSE TYPE
BUS. LIC #
COMPANY NAME E-MAII
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STREET ADDRESS CITY, STATE, IIP
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ARCHTTECTM4GINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSTIL
TYPE
# STORIES
_
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NETAREA
-
BATHROOM
KITCHEN
OTHER
REMODELAREA
REMODELAREA
REMODELAREA
PORCH AREA
DECK AREA
TOTAL DECKIPORCH AREA
I GARAGE AREA: LJ DETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? []NO
ADDITION? []NO
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RE
C=
TOTAL VALUATION:
PLANNING APPL # [-]NO PLANNING APPROVAL LETrER
KICHLER HOME? ❑ NO
Z'c�r oov _
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13y my signature below, I certify to each of the following: I am the property owner or aUthorizeck4ent to act on the pr9perty owner's behalf. I have read this
application and the information I ha a rovided is correct I have read the Description of Work64 verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating ding c tion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
P TM
ROUTING SLD'
-oma-TRE-COUNTER
ElBUILDING PLAN REVIEW
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.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ sTANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑LARGE
❑ F>xE nm- r
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER Dm-RICr
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
Bldgflpp_2011.doc revised 06/21/11
Z 7(
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CU P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS:!('
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PERMIT # :. .. D
OWNER'S NAME: Q,n
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PHONE # `'- •— / �f S
GENERAL CONTRACTOR%
BUSINESS LICENSE #
ADDRESS:
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CITY/ZIPCODE• . G
*Our municipal code requires all businesses working in the city to have a City of Cupertmo.:.usiness license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) W -ILL. BK' SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTR
ACTORS HAVE OBTAINED A"CITY OF CUPERTINO
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
/
Date
Contractor 1gnature