12080194 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19980 PORTAL PLZ CONTRACI'OR:KRT INC PERMIT NO: 12080194
O\VNER'S NAME: NAM&IIYUN CIIO 21001 SAN RAMON VALLEYBLVD DATE ISSUED:08/27/2012
OWNER'S PIIONE: 4088737133 SAN RAMON.CA 94583 PHONE NO:(925)5560612
❑ LICENSED CON'1'RACI'OR--SDECLARATION BUILDING PERMIT INFO: BLDG I— ELECT ri PLUMB(-
License Class _B �e
• Lic.4 J 4 10 J� r Cl, r
�/ DIECH RESIDENTIAL COMMERCIAL
Contractor_p 27L _�__NC Dat, (ate �.
1 hereby affirm that I am licensed under the provisions of Chapter 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 elrect. REROOFING
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
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 die performance of die work for which this Sq.Ft Floor Area: Valuation:$1500
permit is issued.
API'LICAN'1'CF-R'I'IFICA'1*101V APNNumber:36945002.00 Occupancy Type:
1 certify,that 1 have read this application and state that the above information is
coffee[.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 dexpenses harmless the accruty e against
Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
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. � L
IKC Issued by: �Ei4.✓ FI%GrJ Date: a'-aJ-/,2
Signature1�� Date �.�.�r
❑ O\VNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beiig 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 stimaure 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 COVERINGS TO 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 HAZARDOUS MATERLU 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. 1 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 I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Qualily Management District I will
1 certify that in the performance of the work for which this permit is issued.I shall maintain compliance with the Cupertino Municipal Code,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 of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must C) d agent:
m rze
forthwith comply with such provisions or this permit shall be deemed revoked. Date: I
APPLICANTCF.RI'I FICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances and state 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 liabilities.judgments, 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 ARCI IITECI"S DECLARATION
with all non-point source regulation per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CONSTRUCTION PERMIT APPLICATION I ��
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION O
10300 TORRE AVENUE•CUPERTINO CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•buildinG(d),cuoertino.orD 12
❑NEW CONSTRUCTION El ADDITION ❑ ALTf:RATION/TI ❑ RFVISION/DEFERRED ORIGINAL PERMIT♦H
PROJECT ADDRESS k Ob c,AA A24 APNa r� 0 V 12-
OWNERNAAIE . IQm � n PH \qC, Ell, `✓1 `f .
STREET ADDRESS 1 j v p n�\ Q1 CITY.N ATE.ZIP C� ��J FAX
CONTACT NAME PHONE PHONE T E,NAIL
5 w
STREET ADDRESS cn Y,STATE,ZIP FAX
19OWNER ❑ OWNER-BUILDER ❑ OW:NERAGENT ❑ CONTRACTOR CICONTRACTORAGENr ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �/!O ( ,( ` / LICENSE NUMBER T S9 LICE\SE TYPE Q BUS.LIC>30(faG
CONIPANY NAMB KR t T IU C- E-,NAIL `J �X O�
STREET ADDRESS C_ AT CTfI'.SPATE;ZIP HONE
.11001 5 ,, eFMO Vg14k173L-1/p sAA, 2a/YLon CA (45 s 5S6-a63;1-
ARCHTTECTIENGINEER NA.NIE Aj LICENSE NUMBER BUS.LIC Y
COMPANY NAME E-NAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
E o✓� �� P�� L� �aDo
1 - -
EXISTING USE PROPOSED USE CONSTR.TYPE I I40RIF5
USE TYPE OCC SQ.FT. VALUATION(,)
WSTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATNROOSI KJTCHEN OTHER
REMODEL AREA REMODEL AREA RENODELAREA
PORCH AREA DECK AREA TOTAL DECK RCH AREA GARAGEAREA: DETACH
ATTACH
Y DWELLING UNm5: 15 A SECOND UNIT [I YES SECONDSTORY YES
BEING AO@:0^ QNO ADDITION} NO.
PRE-APPLICATION DYES IF YES,PROVIDE COPY OF IS THF,BLDG AN ❑YES "BEGET\ B �V a - TOTALVALUATION:
PLAPNP'G APPLY ANO PLAp'NING APP0.0V AL LETTER EICIILER II(IMF:'. �Np ! �,-R 4
By my signature below,I certify to each of the following: I am the property owner or amhori e o act on the property owner's behalf. (have read this
application and the information 1 have provided is correct. 1 have read the Description of Work end v y it is accurate. 1 agree to comply with all applicable local
ordinances and scare laws relating to building construction. I author'v'e repmsenM.Yes of Cupertino t nter the ap ve-iden'Eed property for inspection purpose.
Signature of ApplicandAgent". d-0Jl— •Date: p� �1
SUPPLEMENTAL INFORMATIONRE UIRED �MMP "M"^"•""""' -ry�'y7ir`�"ko(iiluc SlD
Q rwNrxLn.TYPE;;r�,`r�1".New$PD or Multifamily dwellings: Apply for demolition permit for ` ' ttP,3. ".`a
O\ER-THE-COUNTERC':L' ❑iBUB.DI\G PL,f\REVER f 44,
existing building(s). Demolition permit is required prior to issuance of building .g a
permit for new building. Oy`ENPRF55 ,� 'fi* ,A }„ uNNTNc pLpN}REYtEw-r dtk`� ,
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Osr\NnnRD , t�`PUBLJewoRLs'-x^'t� t f is
Tom if any Hazardous Materials are being used as pan of this project.
�❑ LARGE,: +P+2'Y.. ❑YFIRE DEPT iZ. 4 t J
Copy of Planning Approval Letter or Meeting with Planning prior to
.vi,60 X� DsANJITARY Jt N F R Or 11
submittal of Building Pemrit application.
4 10 � ❑�t:N\IRONML\TAI;IIKAI,Td�'iaa{'
81dgApp_2011.dDc revised 06121111