12040072CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10185 PARKWOOD DR
CONTRACTOR: STEVE PLEVANCIC
PERMIT NO: 12040072
CONSTRUCTION
OWNE.R'SNAME: AVERY GLENBROOKLP
528 S h1ATHILDA AVE STE 2
DATE ISSUED: 04/122012
OWNER'S PHONE: 6509618330
SUNNYVALE., CA 94086
PHONE. NO: (408) 8049145
❑ LICENSED CONTRACTOR'S DECLARATION
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License Class___ Lic:# L/
BUILDING PERMIT INFO: BLDG ELECT PLUMB
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Contractor �.r.2• r. P10VA A -- Date '
MECH RESIDENTIAL COMMERCIAL
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REMOVE & REPLACE 36 WINDOWS
(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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. FI Floor Area:
Valuation: $20000
Section 3700 of the Labor Code, for the performance of the work for wh' 's
APN Number: 32627037.10185
Occupancy Type:
permit is issued,
APPLICANT CERTIFICATION
I certify that I have read this application and stale that the above information is
correct. 1 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,
OM LAST CALLED INSPECTION.
]80 DA7117;111'1�
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -pin source regulations per the Cupertino Municipal ode, Section
Issued y: Date:
9.18.
Signature /
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RE -ROOFS:
❑ OWNER -BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
I, 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 (Sce.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct Ilse project (Sec.7044, 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 Code, 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 Worker's Compensation Insurance, as provided for by
Addilionally, should 1 use equipment or devices which emit hazardous air
Section 3700 of One Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued,
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the perlomtance of the work for which This permit is issued,) shall
Health & Safely Code, Sections 25505, 25533, and 25534./�
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate ofcxemption,l
O r a horned agent: Z///,)_k_ 1
' — Date: Ot
become subject to the Worker's Compensation provisions of the Labor Code, I must
lurthwvith comply with such provisions or this permit shall he 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 stale that the above information is
Lender's Name
cored. 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
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
1 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 Dale
12— 9 c -)v-7
CONSTRUCTIONPERMIT APPLICATIO
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 13
(408) 777-3228 • FAX (408) 777-3333 • buildina(DTcuoerlino ora
CUPERTINO I
❑ NEW CONSTRUCTION .❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / Da -ER= ORIGINAL PERMIT e
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DESCRIPTION OF WORK U� T A.. 'A I' -
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A DWELLING IMUS:
ISASEL'ONn UMr YES
SRCONTS'rORY ❑YES
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BamGADBEDT ❑NO
ADnTIDNT ❑NO
PRE -APPLICATION []YES T YES, PROVIDE COPY OF
'ISTREBLDCAN ❑YES
RECSIVEDBy:TOTAL
VALUATION:_
PLANNINGAPPLa ❑NO PLANNDIO APPROVAL LETTER
EICM.ER HOMET ElmZC7r
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By my signature below, I certify to each of the following. I am the property owner or authorized agent to act on the prpperty owner's behalf. I have read this
application and the information I Its a vided is correct I have read the Description of Work and verify it is accmare. I agree to comply with all applicable local
ordinances and state laws relating ding tion. I authorize representatives of Cupertino to enter the above -identified pmperty for inspection purposes.
Signature of Applicant/Agent: Date;
SUPPLEMENTAL INFORMATION REQUIRED
PLAN C9ECICTSPR
ROUTING W M
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❑ eUe.D¢vc PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
building(s). Demolition permit is reclared prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLAsmc; PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
C1STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project
❑ LARGE
❑ Fm DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
_
submittal of Building Permit application.
❑ MAJOR
❑ suHrARYSEwEa oaslRlcr
❑ ENVBONcAL BPALTB
d(dgApp_201 Ldoc revised 06/31/11