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12080192 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRISSS: 19976 PORTAL PLZ CONTRACTOR:KRT INC PERMIT NO: 12080192 OWNER'S NAME: ALFREDO ORTIZ 21001 SAN RAMON VALLEY BLVD DATE ISSUED:08272012 OWNER'S PRONE: 6509616000 SAN RADION,CA 94583 PIIONF.NO:(925)5560632 ❑ LICENSED CONT'RAC`fOR'SCD'ECLARATION BUILDING PERMIT INFO: BLDG I_ ELECT r PLUNIB 1- License Class B Lic.q /'�T q0 7' r F7C ( � MECH RESIDENTIAL COMMERCIAL ft-2 7 Date 8 I 1 hereby affirm that 1 am licensed under the provisions of Cha pier 9 JOB DESCRIPTION: REMOVE&REPLACE CLERESTORY WINDOW TO (commencing with Section 7000)of Division 3 of the Business& Professions FACILITATE Code and that my license is in full force and effect. REROOFING 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 perfomtance 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 Sq.Ft Floor Area: Valuation:$1500 permit is issued, Al'PLICSIV'I'CER-I'117ICX-I'ION APNNumber:36945004.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: , Date: Signature- ,6 Date-2 f a�;I— ❑ OWNER-BUILDER DECLARA'T'ION RE-ROOFS: 1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material berg installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGSTO BE CLASS"A"OR BETTER 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 DA-1,ARDOUS NIAT-ERIAI S DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Ilealth&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code.Section 25532(a)should I store or handle hazardous material. Additionally,should 1 use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Ray Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate ofexemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Own+ o n agent forthwith comply with such provisions or this permit shall be deemed revoked. Date: �( APPLICANT'CERT'IFICAT'ION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is 1 hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city am]county ordinances and stale laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against Iiabilities,judgmems, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCUIT EC`T'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Dale Licensed Professional CONSTRUCTION PERMIT APPLICATION 0 1 LEI COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION A �� 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 1 JIB// CUPERTINO (408)777-3228• FAX(408)777-3333•buildinD(d)puperiino.om ` ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS `�Irl % Pof\ }�� APNM OWNER NAn1E is f T0. `\ PHOSE E-1I a- . 13o'\ O ocaV l/v . STREET ADDRESS ` \ CITY.STA- .,.ZIP y\ FAX Yt{,o C,A q6o� CONTACT NAMEC PHOT E-,HALL 7scc}e- GS STREET ADDRESS CRE,ZIP Y,STATFAX XOWNER ❑ OWNER BUILDER ❑ OWNERAGESo' CONTRACTOR O CONTRACTOR AGENT ARCHITECT ClE1'GINEER ❑ DEVELOPER 11 ANT CONTRACTOR NAME VeRI � ,t , / LICENSE NUMBER ,J9 ^ LICENSETYPE p BUS.LIC I-7DIf �` COMPANY NANIE K R T lUly — e E-null `S �j •J F % IJr O t�0 STREET ADDRES5 ,\ 1- C— •,� CITY,STATE,ZIP HONE 1to01 S � 2an,o 44e�3L-Vn S N 2AvLot1 GA gL{S83 S 556-06 ARCHITECTIENGINEER NAME - LICENSE N'UNSBER BUS,LICA COMPANY NAME 11EMAIL FAX STREET ADDRESS CRY,STATE,ZIP PHONE DFSCRIPITON OF WORK ec" GJxxjP c)(,) oto oe ZcJ= EXISTING USE PROPOSED USE CONSTR.TYPE I PSTORIES USE TYPE OCG SQ.FT. VALUATION(S) EXISTG NEWFLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODELAREA REMODEL AREA REMODELAREA PORCN AREA DECK AREA TOTAL DECKn'ORCH ARG GARAGE AREA: DETACH ATTACH I DWELLING UNITS: ISASFECONDUNIT YES SECOND STORY YES pEINGADDED' �NO ADDITION? oNO PRE-APPLICATION ❑YTS IF YTS,PROVIDE COPY OF ISTHF.BLDG AN ❑VFS 'RECEIVE B}/\(�,,::,-:;-- f TOTAL VALUATION: PGN'NINGAPPL• CINO PLANNING APPROVAL LETTER EICIILER IIUhIE^ []NO � .I •I_ ' //,{ rjt °'i tiG �y__T✓J ' O By my signature below,I certify to each of the following: I am the property owner or authorized igen act on the property owner's behalf. 1 have read This application and the information 1 have provided is correct. I have read the Description of Work and Ve fy it is actuate. I agree to comply'with all applicable local ordinances and State laws relating to building construction. I authorize representatives of Cupertino to enter the abov -Identifi property for inspection purposes. Signature of Applicant/Agent: _ •Date: r? SUPPLEMENTAL INFORMATION REQUIRED r'�.G.nPL\\CHECK'T\'PE�'r:�R e:TJrI�.%t2.N .ROUTING SI.m.�N`::. New SFD or Multifamily dwellings: Apply for demolition permit for -`��\+-kms'{ �'r ate e •*'�� O\ER THL-COUXTER "�- I ❑ BUILDIXG PLAN REVIEW \ eXisting building(s). Demolition permit is requiied prior to issuance of building c zr ri J y. s r -K z a = 4. i Ar s�u3z. permit for new building. ❑3 EXPRESS"-�- ,V#> +, �Or PLAN"ING P1.6'RE\IEEW, ,�c. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ DAR D= �-` - ❑°r uuewoRRs y Lr Tom if any Hazardous Materials are being used as pan of this project. I tyda- r ' - ' v 1• rr,,e', i ".�-i d., +❑ L\RCL .,., ❑ FlRE DFPI'w:� _Copy of Planning Approval Letter or Meeting with Planning prior to #Y''x „b'X •'t-a , z,-< ")`e,r"G'o"u' F ' F❑ \I\JOR "+ j ❑pSANiTAR}SFwLRDISTRICT submittal of Building Permit application. ^'��vu`-" \ � ,- + < p ti�h`LtiiV';': ' � : °."•-� . ❑"tom\IROXME\TAI�tIEAL f11T'in; BldgApp_201 J.doc revised 06/11/11