11090131 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10264 PARKWOOD DR CONTRACTOR:AVERY PERMIT NO: 11090131
GLENBROOK LP
OWNER'S NAME: AVERY GLENBROOK LP 130 E DANA ST DATE ISSUED:09/20/2011
NNER'S PHONE: 6509618330 MOUNTAIN VIEW, CA 94041-1508 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr—BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# f— f— F_
MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ALL UNITS-MULTI-FAMILY REPLACE 8 WINDOWS
NON-STRUCTURAL BEDROOMS TO MEET EMERGENCY RESCUE
(commencing with Section 7000)of Division 3 of the Business&Professions AND ESCAPE.
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
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 APN Number:32627037.10264 Occupancy Type:
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 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 DAYS FROM 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: J Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature .. Date 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 contra or to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.9.5 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 M cipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a) Id I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use e i ent or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Aeea Air Quality anagement District I
performance of the work for which this permit is issued. will maintain compliance with tb ti Municipal de,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code ti 5,2553 ,. 255 -- - j
Section 3700 of the Labor Code,for the performance of the work for which this ( ��
permit is issued. Owner or authorized Date:
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 CONSTRUCTION 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. 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 prop5oy for inspection purposes.(We)agree to save
demnify and keep harmles City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
.,osis,and expenses whic y accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this perm . Aitionally,the applicant understands and will comply
with all non-point urs regulations per the gjiperfTo Municipal Code,Section Licensed Professional
9.18. �
Signature / Date f /d
1
I
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• building aecupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN BP#
OWNED NAME OWNER ADDRESS
/`tL/e-P- / �t �'3�� t*.P t30Z'.
DESCRIPTION OF WORK: W r 1�UVO \ C."A—
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECT ONS:Please read and initial each statement below to signify you understand or verify this information.)
1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Bu der" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
krancinse coverage for injuries to workers on my property.
understand building permits are not required to be signed by property owners unless they are responsible for
th construction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
ketead of myown.
understand Contractors are required by law to be licensed and bonded in California and to list their license
on permits and contracts.
- I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
t I value of my construction is at least five hundred dollars($500), including labor and materials, I may be
onsidered an"employer"under state and federal law.
6. 1 understand if I am considered an "employer' under state and federal law, I must register with the state and
f eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me o serious financial risk.
7. 1 understand under California Contractors'State License Law, an Owner-Builder who builds single-family
r idential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
censed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is pert ed under contract with a licensed general building Contractor.
8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
y financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
efects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14110
9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United States SmaH Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that
a he arty legally and financially responsible for proposed construction activity at the site address listed above.
Vla
ree that, as the party legally and financially responsible for this proposed construction activity, I will abide
able laws and requirements that govern Owner-Builders as well as employers.
ree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issue�tthhiform must be completed and signed by the property owner and
returned to the agency responsible fong the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification le to the citV av be required to be presented when the permit is issued
to verify the property owner's sign
Property Owner's Signature:(-,-," Date: 9
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(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwnerBuilderFonn 2010.doc revised 04114/10
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 - B
CUPERTINO (408)777-3228 • FAX(408)777-3333 • building(5cupertino.orq
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/Il ❑ REVISION/DEFERRED ORIGINALPERNUT#
PROJECT ADDRESS ` � 961 1 �Cq�r 1� �Ci C-A � (
$ .,-1 63-7 - I 1t)2w
OWNER NAME V L� PHO'61-O_Q L 1-$k E �NYIfL s ijJyl(¢cr.
STREET ADDRESS
SS f�,�J P� s� CITY, T ,✓I- Lsj 1 C.� F r y�O/,O 6/ Z 7�
CONTACT NAME
S�^��' ✓C 7 �.LIJA�C�C� 6' �� `f')� E.7'/L � �tJ
STREET ADDRESS CIiY,STATE ZIP F
Y ,� ,��, e
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMELICENSE NUMB ) �/ LICENSE TYPE BU . IC#
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COMPANY NAME E-MAIL ig' 5 r' l
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STREET ADDRESS 1 c -�J� CITY,STATE,ZIP ONE
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ARCHTrfiCTIENGINEER NANE N�.,I_ LICENSE NUMBER BUS.LIC#
COMPANY NAME YY E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORKA+�1; lv Qj •��, w C
L A+>
EXISTING USE PROPOSED USECONSTR.TYPE I #STORIES
USE TYPE OCC. SQ.Fr. VALUATION(5)
EXI TO NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UATr ❑YES SECOND STORY ❑YES
BEING ADDED? []NO ADDITION? []NO
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 z
I-
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 ha e 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 enter the above entife property for inspection purposes.
Signature of Applicant/Agent: Date: ` L)
SUPPLEMENTAL INFORMATION REQUIRED PIAN CE TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW
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 WORIss
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FM DE
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANTTARY SEWER DISTRICT
-sbmittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_Z011.doc revised 06/21/11