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11070159 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19932 PORTAL PLZ CONTRACTOR:KRT INC PERMIT NO: 11070159 OWNER'S NAME: SOMEKH TAL ET AL 21001 SAN RAMON VALLEY BLVD DATE ISSUED:07/29/2011 "H'ER'S PHONE: 4087384221 SAN RAMON,CA 94583 PHONE NO:(925)556-0632 G LICENSED CONTRACTOR'S DECLARATION ` <% BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class C Lic.# [ -1 � MECH� RESIDENTIAL� � COMMERCIAL � ffContractor`� ,1. tti �- Date � ` , I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE&REINSTALL CLERESTORY WINDOW TO (commencing with Section 7000)of Division 3 of the Business&Professions FACILITATE ROOF REPLACEMENT 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 Sq.Ft Floor Area Valuation:$1800 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:36945014.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature _ Date Issued by:t ��' " � Date: OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain [have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& 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. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith forthwith comply with such provisions or this permit shall be deemed revoked. O �ent: r Date: r APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, ts,and expenses which may accrue against said City in consequence of the Lender's Address .ting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 4 ITEMS OF 28 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36945014 . 00 DATE ISSUED. . . . . . . : 07/29/2011 RECEIPT #. . . . . . . . . : BS000014250 REFERENCE ID # . . . : 11070159 SITE ADDRESS . . . . . : 19932 PORTAL PLZ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : SOMEKH TAL ET AL ADDRESS . . . . . . . . . . : 25652 MOODY RD CITY/STATE/ZIP . . . : LOS ALTOS HILLS, CA 94022-4406 RECEIVED FROM . . . . : KENNETH R TROUT CONTRACTOR . . . . . . . : KENNETH R TROUT LIC # 30426 COMPANY . . . . . . . . . . : KRT INC ADDRESS . . . . . . . . . . : 21001 SAN RAMON VALLEY BLVD CITY/STATE/ZIP . . . : SAN RAMON, CA 94583 TELEPHONE . . . . . . . . : (925) 556-0632 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1.00 41. 00 0 . 00 41 .00 0 . 00 1BCBSC VALUATION 1, 800 . 00 1. 00 0. 00 1.00 0. 00 1BSEISMICR VALUATION 1, 800.00 0.50 0. 00 0 .50 0. 00 1STINSP UNITS 1 .00 130. 00 0. 00 130. 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 172. 50 0. 00 172 .50 0. 00 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 19932 portal plaza DATE: 07/21/2011 REVIEWED BY: bobs. APN: J ' 7 BP#: 110-7®I 'VALUATION: 1$1,800 RIPERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: WORK remove and reinstall clerestory window to facilitate roof replacement SCOPE F-1 LJ L NOTE: Theseees are based on the preliminaryinformation available and are onlyan estimate. Contact the De t or addn'l in o. FEE ITEMS (Fee Resolution 11-0531.ff' 7;'1%'ll) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl.PC Fee: G Reg. 0 OT 1 0.0 1 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: Hourly Only? E)Yes 0 No $0.00 Suppl.Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: Yes E) No $0.00 0 Work Without Permit? Yes E) No $0.00 Planning Fez: $0.00 0 hours Inspections G $130.00 ISTINSP Inspection,Hourly Strom Motion Fee: IBSEISMICR $0.50 =hrs Admin./Clerical Fee Bldg Stds Commission Fee: IBCBSC $1.00 $41.00 1ADMIN SUBTOTALS: $1.50 $171.00 TOTAL FEE: $172.50 Revised: 07/04/2011 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 �`� C U P E RT i N U (408)777-3228• FAX(408)777-3333-building(@cupertino.org \\O ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS i PO�`��` `� Q APN# 3 ^ L s:;- OWNER OWNER NAME 1 _ _ C/ L' S C� PHONE STREET ADDRESS .TA L 0T /► � CITiY,,STATE IP CONTACT NAME 1 ,v` �j E-M%(A.+IL) ��S- 5S"6-off AE - -XrjC . S!?c-G ���.dje STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME T T LICENSE NUMBER-)S LICENSE TYPE BUS.LIC N J.- I-f q �c $- G 3�— 3 0 ;LG COMPANY NAME E-MAIL K i ANG KtZTyn�c al SBc�wC,41'. Ne— FAX STREET ADDRESS CI Y,STATE ZIP PHONE stool S Ran.o� VgccEy ��>e ��'-IS) TA CA Lf58 0 C ARCHTECT/ENGINEF,R NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK /^��' re-0V SG �N �' L/� C �L STOP �J !:r pal)O 1, ''f' t> 'FA e 20o f /Y,,rL—cv r EXISTING USE PROPOSED USE CONSTR.TYPE k STORIES O CE USE.. Y. D N VALUATION EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK71SASECONDUNIT TOTAL DECK/PORCH AREA GARAGE AREA:❑ DETACH ❑ ATTACH n nwl..I.I.I N(:1 M1iS ❑YI,� SECOND STORY ❑VI:S BEING ADDED' ❑NO ADDITION' ❑NO PRI:APPI.ICAIION ❑ YU:.S 11:YES.PROVIDE COPY OF I PIA IRS NAME RECEIVED BY.. TOTAr.vaL{JaTto, Pf.ANN]NG AI'PL.q [3NO PLANM NG APPROVAL I.S:1'11:R 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 have read this application and the information i have ovided is correct. I have read the Description of Work and verity it is accurate. I agree to comply with all applicable local ordinances and state laws relati to orize representatives of Cupertino to enter thei-id ntifi property for inspection purposes. Signature of Applicant/Agent: Date- SUPPLEMENTA INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _ New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER El sulLDnvG PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑;PLANNING PIAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD ❑ P[IBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ 'LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑ MAJOR ❑ 5AM' TARYSEWCRDISTRICT © ENVIRONIV10rrAL HEALTH BldgApp_201 1.doc revised 03/16/11