B-2017-0160CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS:
10190 PARKWOOD DRAPT 5 CUPERTINO, CA (326 27 037)
NAME: AVERY GLENBROOK LP
OWNER'S PHONE: 650-961-8330
LICENSED CONTRACTOR'S DECLARATION
License Class CIO, C20, C36, CM Lic. #25M
Contractor THERMAL MECHANICAL Date 01/31/2„018
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.
I hereby affirm under penalty of perjury one of the following two declarations:
L 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
1 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 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 with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
Date 01/31/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
L 1, 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)
2. 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec,7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
11 1 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
Section 3700 of the Labor Code, fbr the performance of the work for which this
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 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.
CONTRACTOR: PERMIT NO: B-2017-0160
THERMAL.
MECHANICAL
SANTA CLARA, CA
95054
DATE ISSUED: 01/31/2017
PHONE NO: (408) 988-8744
APPLICANT CF,RTIFICATION
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 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 with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature Date 01/31/2017
BUILDING PERMIT INFO:
X BLDG X ELECT X PLUMB
X MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
BLDG 54/UNIT 5; ADD (I) A/C; REPLACE FURNACE, SAME
LOCATION; (N) WASHER AND DRYER HOOK UPS; (I) ELECTRICAL
SERVICE (70 AMP); (N) GAS LINE FOR STOVE; (N) RECEPTACLE
OUTLETS; (N) LIGHT; (N) BATHROOM EXHAUST FAN
Ft Floor Area: I Valuation: $20000.00
"N Number: Occupancy Type:
326 27 037
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: MELISSANAMES
RE-ROOFS-
All
F ROOFS: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.
Signature of Applicant:
Date: 01/31/2017
ROOF COVERINGS TO BE CLASS "A” OR
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 255 3 and 25534.
Owner or authorized agent:, `
Date: 01/31/2017
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 - FAX (408) 777-3333 • building@cupertino.org 0
NEW CONSTRUCTION M ADDITION MX AT.TFRATTnmiTl F-1 RFS/TQTr1M1n-xcrinnn nnrn_.nret
BIdgApp2011,doc revised 06121/11
PROJECT ADDRESS 10190 Parkwood DR, BLDG 54,,Unit #5
APN#
OWNERNAME Avery Gienbrook LLC
PHONE
650-961-8330
E-MAIL
avert'@pacbell.net
STREETADDRESS 130 East Dana Street
CITY, STATE, zip Mt. View, CA 94041
Fax 650-961-0571
CONTACT NAME Rob Moyer
PHONE 408-593-8115
E-MAIL rmoyer@thermalmech.com
STREETADDRESS 425 Alda ave,
CITY, STATE, ZIP
Santa Clara, CA 95054
FAX 408-988-0233
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRAGI'ORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEvELOPFR ❑ TENANT
CONTRACTOR NAME
LICENSEMechanical LICENSE NUMBER 256057
LICENSE TYPE
BUS, LIC 9 299
C-4,10,20,36,38
COMPANYNAME Thermal Mechanical
E-MAIL rmoyer@thermalmech.com
FAX 408-988-0233
STREET ADDRESS 4255 Aldo ave,
CITY, STATE, ZIP Santa Clara, CA 95054
PHONE 408-988-8744
ARCHITECTIENOINEER NAME
LICENSE. NUMBER
BUS. LIC #
COMPANY NAMEE-MAIL
FAX
STREET ADDRESS
Crrv, S'rNrr, zn,
PHONE
DESCRIPTION OF N electrical panel 70 -AMP ,
add new AC, replace furnace in same location, {N} washer/dryer hook ups, (N) p ( )
(N) gas line for stove, (N) electrical outlets, (N) light, (N) bathroom exhaust fan
EXISTINGUSE
PROPOSED USE CONSTR,TYPB
#STOlUES
I
US77F
7771
OCC.
SQTT.
VALUATION ($)
I&'CiSTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
-
REMODF,LAREA
REMODELARFA
REMODELAREA
PORCH AREA
DECKAREA
TOTAL DECKIPORCH AREA
GARAOEAREA: ❑DETACH
D ATTACH
I
# DWELLING UNITS:
IS A SECOND UNrr ❑YES
SECONDSTORY []YES
BRING ADDED? []NO
A1)DrrI0N? []NO
PRE-APPL[CA'1'ION []YTS IF YES, PROVIDE COPY OF
PLANNINGAPPLO LINO PLANNING APPROVAL LETTER
IS TTIE TII.UG AN ❑YES
EICHLER HOME? L]NO
GENE
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By my signature below, I certify to.each of the following: I aln the property owner or authorized. gent to net t mperty owner's behalf. I have read this
application and the information I have provided is cotTect. 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 to but ' tt tion. I aut riz representatives of Cupertino to enter the above -identified pr perty for inspection purposes.
Signature of Applicant/Agent: �--- Date: r --W117
SUPPLEMENT L INFORMATION REQ-7 D
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Now SFD or Multifamily dwellings: Apply for demolition permit fo
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existing building(s). Demolition permit is required prior to issuance Of building
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permit for new building.
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_ Commercial Bld s: Provide a completed Hazardous Materials Disclosure
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form if any Hazardous Materials are being used as part of this project.
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Copy of Planning Approval Letter or Meeting with Planning prior to
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submittal of Building Perinit application.
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BIdgApp2011,doc revised 06121/11