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B-2017-0381CITY OF CUPERTINO BUILDING PERMIT ADDRESS: 10224 PARKWOOD DRAPT 8 CUPERTINO, CA 95014-1535 (326 27 037) OWNER'S NAME: AVERY GLENBROOK LP OWNER'S PHONE: 650-961-8330 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor AVERY GLENBROOK LP 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 that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 1. 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. 2. 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 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. L0=6kJM Q I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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) A-2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). CONTRACTOR: PERMIT NO: B-2017-0081 AVERY GLENBROOK LP 130 E DANA ST APT 8 MOUNTAIN VIEW, CA 94041-1508 ISSUED: 03/21/2017 PHONE NO: BUILDING PERMIT INFO: X BLDG —ELECT _ PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: BLDG 63/UNIT 8 - REPAIR STRUCTURE DUE TO DAMAGE FROM FALLEN TREE Sq. Ft Floor Area: Valuation: $10000.00 "N Number: Occupancy Type: 326 27 037 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 D SPECTION. Issued by: MELISSA NAMES Date: 03/21/2017 RE -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: 03/21/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" 1. 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. 2. 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. 7yy� �}ry I certify that in the performance of the work for which this permit is issued, I 6 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. APPLICANT CERTIFICATION 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. 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, Secti2iLq5505,25533, and 25534. Owner or authorized agent: fN LENDING / Date: 03/21/2017 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 Date 03/21/2017 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(�i_)cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDREJS 10224 Parkwood DR, BLDG 63, Unit #8 7APN# OWNERNAME �Ve GlenbrOOk LLC ry PHONE 650-961-8330 E-MAIL avery@pacbell.net rY@P STREETADDRES$ 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 STREET ADDRESS � 130 East Dana Street CITY, STATE, ZIP Mt. View, CA 94041 FAX 650-961-0571 0 OWNER +OWNER -BUILDER EXOWNERAGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT i CONTRACTOR NAME '' LICENSE NUMBER - — T.ICFNCF i'YPF. BUS. LIC # COMPANY NAMEI E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME I E-MAIL FAX STREET ADDRESS I CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Structural repairs due to damage to unit by fallen tree EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA ' 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 UNIT ❑YES SECOND STORY [I YES BEING ADDED? []NO ADDITION? []NO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑YES B TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO - -fry ` By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I hake read this application and the information I have provided 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 to build onstru 'on. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: % SUPPLEMENAL INFORMATION REQUIR-15b PLANCHECKTYPE ROUTINcsup, 0 bVER_TIIE-C0UNTRB Q BUILDINGPLAN 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 El sTANDARI> PUBLIC WORK_ s _ form if any Hazardous Materials are being used as part of this project. I� LARGE FIRE DEF? , Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR SANITARY SEWER DISTRICT submittal Of Building Permit application. ENVIRONMENTAL HEALTH BldgApp_2011.doe revised 06121/11 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE VENUE_ • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildina(dicupertino.ora 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: /h 17 1� It x, SITE ADDRESS z z OYVNER NAME flab ��� 0 NER ADDRESS ! IF. ebe, S % i/ ` t,/ G!g- �O DESCRIPTION OF WORK: Re o241 r 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 (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) k: (! understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, 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 insurance coverage for injuries to workers on my property. I%W2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 1 vi-v'3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may `protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. �'•'4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license ,numbers n permits and contracts. II understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be consider an "employer" under state and federal law. i 6, 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal 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 to serious financial risk. of 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is ed under contract with a licensed general building Contractor. is as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 0w7?e7Bzd1de7F07"111 ?010. doe revised 04/14110 W9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal IiI Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, I 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. Y�/10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. At -1101'. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. . 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I 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/)(cd form must be completed and signed by the property owner and returned to the agency responsible or issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification ac pliable to the Dity may be required to be presented when the permit is issued toyeri the ro ert owner's sidnatu e d Property Owner's Signature�f �� Date:' -- g -T --The --p -- y- ------ z t -=o ---- - - .- �-.------------------------ ------------------------------------------- (NOTE. The following Authorization Form is requir to f e completed by the property owner only when designating an agent of the property owner to apply for a construe ion 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): p �noF ke-A* AS Project Location or Address: Name of Authorized Agent: Rob 1110(eel n Tel No y®$ — 513— ?115 Address of Authorized Agent: L/ C, C_ nc /gra C� 17%0$7 I declare under penalty of perjury above information and certify its verification acceptable to the city/ signature. Property Owner's Signature: 1 am the property owner for the address listed above and I personally filled out the racy. Note: A copy of the property owner's driver's license, form notarization, or other be required to be presented when the permit is issued to verify the property owner's 3 Date: 21_17 Oi+�7ie7Builde7Fo7-7722010.doe revised 04114110