10060163CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11891 PLACER SPRING CT
CONTRACTOR: KAREN S. KENISON
PERMIT NO: 10060163
OWNER'S NAME: KAREN S. KENISON
11891 PLACER SPRING CT
DATE ISSUED: 06/25/2010
OWNER'S PHONE: 4087251732
CUPERTINO, CA 95014-5103
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL 13
License Class Lic. #
REMODEL 150 SQ FT TO KITCHEN CHANGE CABINETRY,
COUNTEROPS, APPLIANCES,FLOORING AND WINDOS
Contractor Date
REPLACE
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
SUB PANEL ON LAUNDRY ROOM
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 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
Sq. Ft Floor Area:
Valuation: $120000
performance of the work for which this permit is issued.
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: 36655013.00
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: 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:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business &Professions Code).
1 have read the hazardous materials requirements under Chapter 6.95 of the
J
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
1 hereby affirm under penalty of perjury -one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should 1 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 Quality Management District 1
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections•25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
CQ,L�1
permit is issued.
Owner or authorized agent: g Date: O
-
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, 1
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
1 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 property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
1 understand my plans shall be used as public records.
granting 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 S`. Date Z 0
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36655013.00
DATE ISSUED.......: 06/25/2010
RECEIPT #.........: BS000010711
REFERENCE ID # ... 10060163
SITE ADDRESS .....: 11891 PLACER SPRING CT
SUBDIVISION ......
CITY .............: CUPERTINO
IMPACT AREA ......
OWNER ............: KAREN S. KENISON
ADDRESS ..........: 11891 PLACER SPRING CT
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5103
RECEIVED FROM ....: KAREN KENISON
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: KAREN S. KENISON
ADDRESS ..........: 11891 PLACER SPRING CT
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5103
TELEPHONE ........:
FEE ID UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
-----------------------
1BCBSC VALUATION
----------
120,000.00
----------
5.00
----------
0.00
----------
5.00
----------
0.00
1BSEISMICR VALUATION
120,000.00
12.00
0.00
12.00
0.00
1EPERMITFE FLAT RATE
1.00
42.00
0.00
42.00
0.00
1ERTc200 UNITS
1.00
42.00
0.00
42.00
0.00
1REMRESKIT SQ FEET
150.00
570.00
0.00
570.00
0.00
1TRAVDOC FLAT RATE
1.00
42.00
0.00
42.00
0.00
TOTAL PERMIT
-----------
713.00
----------
0.00
----------
713.00
----------
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
NUMBER
----------------- ---------------
CHECK
713.00
--------------------
219
---------------
TOTAL RECEIPT
713.00
CITY OF CUPERTINO DUILDING PERMIT
BUILDING ADDRESS: 11891 PLACER SPRING CT
OWNER'S NAME: KAREN S. KENISON
✓NER'S PHONE: 4087251732
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lie. #
Contractor
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:
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
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 t4 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 win comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature,
Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code). j(>VC,
I hereby affirm under penalty of perjury one of the following three
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
Section 3700 of the Labor Code, for 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.
XStCr
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
,ipon the above mentioned property for inspection purposes. (We) agree to save
demnify and keep harmless the City of Cupertino against liabilities, judgments,
.osts, 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. _%
Ste. Date G
CONTRACTOR: KAREN S. KENISON PERMIT NO: 10060163
1181-1 PLACER SPRING CT DATE ISSUED: 06/25/2010
CUI ERTINO, CA 95014-5103 PHONE NO:
JOI, DESCRIPTION: RESIDENTIAL u COMMERCIAL
RLMODEL 150 SQ FT TO KITCHEN CHANGE CABINETRY,
CC UNTEROPS, APPLIANCES,FLOORING AND WINDOS
REPLACE
SUB PANEL ON LAUNDRY ROOM
Sq. Ft Floor Area:
AP'J Number: 36655013.00
Valuation: $120000
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issied bv: Date.
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
insi ailed without first obtaining an inspection, I agree to remove all new materials for
ins )ection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I hive 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
wil I maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
thi Health & Safety Code, Section&.25505, 25533, and 25534.
Owner or authorized agent: 3 Date:
CONSTRUCTION LENDING AGENCY
I h:reby affirm that there is a construction lending agency for the performance of
we rk'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.
Li:ensed Professional