12100056 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21327 GLEN PI- CONTRACFOR:STEVE PLRVANCIC PERMIT NO: 12100056
CONSTRUCTION
OWNER'S NAME: AVGRY CONSTRUCTION 528 S MATI IILDA AVE STE 2 DATE ISSUED: 10/092012
.OWNF,R'S PHONE: 6509618330 SUNNYVALE,CA 94086 PIIONE NO:(408)806-9145
❑ LICENSED COKIRACI'OR'S DECLARATION JOB DF,SCRIP'1'ION: RESIDEN"I'lALCI COIN \IF,RCIAL
License Class Lie.# APT 2- DECK REPAIR
Contractor Sf ALI(Zvcue Date
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(bat my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have dud 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:$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.
.\PN Number:32627036.21327 Occupancy Typc:
AI'I'I-KAKI'CM:R"I'IPICA"PION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.1 agree to comply with all city and county ordinances and slate laws relating WITHIN 180 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 DAY F OM 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 AAA
v g
granting of this permit. Additionally,the applicant understands and will comply Issued by: Dale: o
with all non-poin ource regu tions per the Cupertino Municipal Code,Section
9.18.
RF,-ROOFS:
Signature Date 9 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.
❑ O\\'NER-Bl11LDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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 die 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 I IA'LARDOUS MATERIALS DISCLOSURE
construct the project(Sce.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Sa rely Code,Sections 25505,25533,and 25534. I will
hereby affirm under penally of perjury one of the fnllnw'ing three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth&Safer,,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 Qualify Management District 1
performance of the work for which this permit is issued. will maintain compliance vs fill(I1Cupertino Dlunicipal Code,Chapter 9.12 a d
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Se s 25 -.533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which thisI �(
Owner or authorized age. 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
Compensation laws of California. If,after making this certificate of exemption,I CONS"TRIICI'ION LENDING AGENCY
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. stork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
,%PI'LICAN'I'CIiR'1'IFICA'1'ION Leader's Address
I certify that 1 have read[his application and slate that the above information is
correct. I agree to comply with all city and county ordinances and state lases relating
to building construction,and hereby nnhorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCIIITEC]'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
grinding of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18,
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21327 Glen Place DATE: 10/09/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PR1111ARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK Deck Repair 224 sq ft).
SCOPE
Much. Plan Check Plumb. Plan Check Elec.Plan Check
hfech. Permit Fee: Plumb.Permit Fec: Elec. Permit Fee:
Other,Mech.Insp. Other Plumb Insp. Other Elce.Insp.
.Meeh.Lup. Fee: Plumb. lay.Fee: Elce.Insp.Fee:
NOTE: This estimate does not include fees due m other Departments(i.e. Planning, Public Works, Fire,Sanitap,Server District,School
District,etc. . These ees are baser/on the preliminarj information rnvdlable and are ardr an estimate. Contact the Dept for adihr7 in a.
FEE ITEMS (Fee Resolution 11-053_L--
.g.' 7/l/ll1 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Deck/Deck Railing
Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 $467.00 IDECKH'00D Deck (wood)
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee0 Reg. Q OT0.0 hrs $0.00
PM.E Unit Fee: $0.00
PME Permit Fee: $0.00
Consnvction Tax:
Adinitiisirarive Fee: O
Work Without Permit? O Yes Q No •$0.00 (D
AdvancedPlannine Pee: $0.00 Select a Non-Residential (D
Travel Doctunenration Fees: Building or Structure
Strone Motion Fee: IRSEISHICR $0.50 Select an Administrative Item
Blda Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $467.001 TOTAL FEE: $468.50
Revised: 10101/2012
CONSTRUCTION PERMIT APPLICATION p'l
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DMSION oO
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 `
CUPERTINO (408)7/7-3228•FAX(408)777-3333•buildina(akupertino.ortl ,l`nv�
❑NEW CONSTRUCTION ❑ ADDMON TERATION/TI ❑ REVISION/DUMM�/ORIGINA/L lrou&f B
PROJECT ADDRESS I3��/'/ �e1') uC- APNO /7 �� l 03(-P. cyj
OWNER NAME /I V&7?- Y C.9C EN��/e . I— p FHOHE61-0-96/—Fr! E.r4Au.AL/1--k yfS ( wc�.�•
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CONAw NAME SCC'.✓� CCU AJJ CRL FYdk-$'Ob�
SIRMT ADDRESS t74, 4-IA-- // lam•�ATF ZIP N 11 e U F
0 OWNFA 0 OWNFA-SUI DER 0 OWNERAGF IIYCONBACIOR 0 cmlRUCTOR AGENr 0 ARcerTEcr 0 EmOINE8 0 DSvE a 0 rcmxr
NNRG HAKE LICENSENUMB i /6 6LICENSETYFE r[ BU&UC.
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COMPANY NAME &MAQ (, F 1G6�7 � 1
STREET ADDHPSS TY,STATE,ZR ONE
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ARCIOTFIT/tNODJP.PANAME T J GCENSENUMBER BUS.TIC0
COMPANY NAME t� E-MAIL FAX
SiRF>7Z'ADDRESS CITY.STATE.ZW PHONE
DESmt4+aON OF WORX - -
Q
n6SrINGUSE PROPOSED USE coNSTR.TYPE SSIOPM3
'Z-1 USE TYPE OCC SQ.FT. VALUATION(S)
EX= N wvt OR DEMO TOrAL
AREA AREA AREA NEr.AREA -
nATHROOM QrQ4N OtEFR
REMODELAREA RFMODELAREA RENODEL AREA
PDRO{AREA DEEXAREA TOTAL DFLR/POR AAFA GARAGE ARFA Dh ACH
ATTACH
R OWPLLaeG tNIR: MASECONDUNTr LjY SE[ONDaTORY Y6
eaneO ADDED? ONO ADUTROM. ONo �j�y.,,.l "
PRE.APPIICATRN DYES W YES.FROVOR COPY OF I mraaz DGAN ❑YES Y: TOTAL VALUA7TON:
PUNNNGAPPLa ONO PIAlQJNG APPROVAL LETTFat ®Cm.IDt HODLLt 0NO
By my sigoamrc below.I certify to each of the following: I am the property owner or authorized agent to act oo the prppetty owoers behalf I have read this
application and the information I vided is correct. I have read the Description of Work and verify it is acnrate. I agree to comply with all applicable local
ordinances and state laws relating dint on. 1 authorize representatives of Cupertino to enter the above-identified property forlinsp2ection purposes.
Signature of Applicant/Age nt Date: �� ' / '! (/
SUPPLEMENTAL INFORMATION REQUIRED PLAN CK T1rPx eomavc sr-v
New SFD or Mudtif oily dwellings: Apply for demolition permit foria'ovMT HE-COUNTER �CBonDutc PUN EzVo w
;est btaldmg(s). Demolition permit is tequimd prior to issuance of building 7`
permit for new building. ❑ EmsFss ❑ PLAXMNCMAN REVIEW
_Commercial Bldgs: provide a completed Hazardous Materials Disclosure ❑ sTA[mARO ❑ t Two..
form if any Hazardous Materials are being used as part of this project.
❑ LARGE ❑ FmE uar
Copy of Ple i g Approval Lcner or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER oa-rwcr
submittal of Building Permit application.
❑ PNP@OKMENTAL BR•rTH
dldgApp_2011.doc revised 06/31/11