11070163 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19940 PORTAL PLZ CONTRACTOR:KRT INC PERMIT NO: 11070163
OWNER'S NAME: LEON&MARGARET TORREY 21001 SAN RAMON VALLEY BLVD DATE ISSUED:07/29/2011
""NER'S PHONE: 4084464718 SAN RAMON,CA 94583 PHONE NO:(925)556-0632
LI LICENSED CONTRACTOR'S DECLARATION
p BUILDING PERMIT INFO: BLDG ELECT PLUMB
License ClassC. Lie.# T f—
MECH RESIDENTIAL COMMERCIAL
Contractor - 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
Code and that my license is in full force and effect. ROOF REPLACEMENT
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. Sq.Ft Floor Area: Valuation:$1800
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:36945010.00 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. -?
SignatureYDate Issued b '' `�— Date: CF- 7( ,
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)
I,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:
I 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 Califomia. 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 comply with such provisions or this permit shall be deemed revoked. O ri ag nt:
Date:�k/
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"Ork'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,
and expenses which may accrue against said City in consequence of the Lender's Address
.ig of this permit.Additionally,the applicant understands and will comply
wan all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1 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 . . . . . . . . : 36945010 . 00
DATE ISSUED. . . . . . . : 07/29/2011
RECEIPT #. . . . . . . . . BS000014250
REFERENCE ID # . . . : 11070163
SITE ADDRESS . . . . . : 19940 PORTAL PLZ
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER LEON & MARGARET TORREY
ADDRESS 901 FERNGROVE DR
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4664
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
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 1, 207.50 MC
---------------
TOTAL RECEIPT 1, 207.50
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19940 portal plaza DATE: 07/21/2011 REVIEWED BY: bobs.
APN: �J 6p tf q S O r BP#: "VALUATION: $1,800
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex lex PENTAMATION
USE: PERMIT TYPE:
WORK remove and reinstall clerestory window to facilitate roof replacement
SCOPE
Li
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (F�e resolution 11-053 f ff' 1,`11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl.PC Fee: G Reg. 0 OT 0.0 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.Feer Reg. 0 OT 1 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: 0 Yes (E) No $0.00
Work Without Permit? 0 Yes G No $0.00 E)
Planning Fee: $0.00 1 hours Inspections E)
$130.00 ISTINSP Inspection,Hourly
Strom Motion Fee: IBSEISMICR $0.50 =hrs Admin./Clerical Fee
Bldg) Stds Commission Fee: IBCBSC $1.00 $41.00 ]ADMIN
SUBTOTALS: $1.50 $171.00 TOTAL FEE: $172.50
Revised: 07/04/2011
CONSTRUCTION PERMIT APPLICATION �✓
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTiNO
(408)777-3228- FAX(408)777-3333•building a)cupertino org
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS
(`;g C> v��T C. ,�Lns �. APN#
2 7tog
O
t a
OWNER NAMEPHONE E-MAILtt!!tr L
STREET ADDRESS°01 i /2Q � L STTE,f
N N
�vD FAX, /
CONTACT
NAME
t PHONE E-MAIL
zdca L, 447
STREET ADDRESS CITY,STATE,ZIP
FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME 7r-
tj c.- LICENSE NUMBERS LICENSE TYPE BUS LIC#
T •L
COMPANY NAME E-MAIL K � ANG FAX
Ki'Z.T=NC-
a sBccwQAL. Nom- Aar
STREET ADDRESS CI Y STATE ZIP
oZ(00� Saar RAekoN uq ec.Ey t,✓� A.�_�S' � PHONE
Mo GA 5$ a�s�5s6-0 �,32—
ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS.LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS --t-
CITY,STATE,ZIP
PHONE
DESCRIPTION OF WORK �^
FA C.- c4e 200�
EXISTING USE PROPOSED USE CONSTR.TYPE N STORIES
O C E Y
DV S
EXISTG NEW FLOOR DEMO TOTAL � /
AREA AREA AREA NET AREA r` r / D 6
BATHROOM KITCHEN OTHER ( CCCJJJ
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH
--- -- ❑ ATTACH
a 1)wl 1A.I1c;IJN11S IS A SECOND UNI-! ❑YL[ SECONDSTORY ❑YFS
BEING ADDED'. ❑NO ADDITION" ❑NO
PRI:-APPI ICAIION ❑ YLS IF YGS.PROVIDE COPY OFPLANNER'S NAME z_
RECEIVED BY: TO �(q�,UATION��
PI,ANNIN(;AI'P1.9 [3 Nn PLANM NG APPROVAL i.F.I I'L:R a�
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 t have 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 relatin to nstr7tion. T authorize representatives of Cupertino to enter the aboVe-identifiked property for inspection purposes.
Signature of Applicant/Agent: Date: '
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE
ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for l,,��rr�/�
existing building(s). Demolition permit is required prior to issuance of building ER-THE-COUNTER a BUILDMGPLAN REVIEW
permit for new building.
EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WOR"
To—mi if any Hazardous Materials are being used as part of this project.
❑ LARGE ❑ PIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ IAaaR ❑ Sh14ITARYSVWERJ*t1YIOT
❑ ENVIRONM RTAL'HEALTIi'
BldgApp_2011.doe revised 03/16/11