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11060080 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19883 PORTAL PLZ CONTRACTOR:KRT INC PERMIT NO: 11060080 OWNER'S NAME: XIAOMEI LIU 21001 SAN RAMON VALLEY BLVD DATE ISSUED:06/10/2011 '"" 'NER'S PHONE: 6509410190 SAN RAMON,CA 94583 PHONE NO:(925)556-0632 LJ LICENSED CONTRACTOR'S DECLARATIONF 1 BUILDING PERMIT INFO: BLDG ELECT" PLUMB License Class -L)- !�Lic.# S T `'r 0 g MECH F RESIDENTIAL F COMMERCIAL� Contractor �� `� Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE&REINSTALL CLERESTORY WINDOW AT ROOF (commencing with Section 7000)of Division 3 of the Business&Professions LOCATION 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 Sq.Ft Floor Area: Valuation:$1800 Section 3700 of the Labor Code,for the performance of the work for whic permit is issued. APPLICANT CERTIFICATION h hi APN Number:36946006.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. 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. Issued by:7„%i Date: Signature y L Date (* OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 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 I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Ow orrz t become subject to the Worker's Compensation provisions of the Labor Code,I must Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION .ling of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 3 ITEMS OF 9 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36946006 . 00 DATE ISSUED. . . . . . . : 06/10/2011 RECEIPT #. . . . . . . . . BS000013724 REFERENCE ID # . . . : 11060080 SITE ADDRESS . . . . . : 19883 PORTAL PLZ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : XIAOMEI LIU ADDRESS 19883 PORTAL PLZ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : KENNETH 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 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 1WINREP EACH 8 1. 00 380 .00 0 . 00 380 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 381 .50 0 .00 381. 50 0 .00 CITY OF CUPERTINO �\ FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 19893 portal plaza bldg E DATE: 06/10/2011 REVIEWED BY: bobs. APN: 3 BP#: 'VALUATION: $1,800 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Du lex PENTAMATION 1GENRES USE: P PERMIT TYPE: WORK remove and reinstall clearstory window at roof location SCOPE Lj Li NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the Det or addh 7 info. FEE ITEMS (I ee Resolution 09-051 Eff.' 7,110) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Window/Sliding Glass Door Suppl.PC Fee: (F) Reg. 0 OT 0.0 1 hrs $0.00 $380.00 1 WINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl.Insp. Fee4O Reg. 0 OT FO.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes 0 No $0.00 0 Work Without Permit? 0 Yes (D No $0.00 Planning Fee. $0.00 Select a Non-Residential E) Building or Structure 0 Stroniz Motion Fee_ IBSEISMICR $0.50 Select an Administrative Item B1dgy Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $380.00 TOTAL FEE: $381.50 Revised: 04/29/2011 Building Department City Of Cupertino LM 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: S g 3 CqL PERMIT# �?4 OWNER'S NAME: (�� PHONE# -�� - Q GENERAL CONTRACTOR: K2� BUSINESS LICENSE# ADDRESS:'�(0,) 11e&kx-.P* b CITY/ZIPCODE: osE/ *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: �� I Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CONSTRUCTION PERMIT APPLICATION a] COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 \\ CUPERTINO (408)777-3228-FAX(408)777-3333•build inaacupertino.ora ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS �� ZA p APN# Ci 8� o 3 �t�' `R�-AL 1`(�.rU 1/� OWNER NAME PHONE E-MAIL ANS L (p - - �I O STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME �r r� PHONE E-MAIL lff �. ot�S- S"S6-off �^ a�lcct S3cGcx�a�.aiti STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAMET• ' LICENSE NUMBER S L 1® LICENSE TYPE BUS.LIC# T J.- R 1 7 bff $ ;LG COMPANY NAME K FAX ANG E-MAIL a Sr�c�waAc.. Nom- par - S C-db 2 STREET ADDRESS CI Y,STATE ZIP PHONE k(001 Sam alnld� �quEy �a o CA S 8 Gi ks--SSb-d G,3 z ARCHITECTIENGINEER NAME LICENSE NUMBER BUS LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORT El1r`OIJ�G EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES O CE USE Y TYPE S0,FT, VALUATION,S EXIST NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER - REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH ❑ ATTACH a Ilwl:l.l.l Nc:I M77'S ISA SECOND UNIT ❑1'ES SECOND STORY ❑YLS ' eE114G ADDED'. ❑NO ADDITION? ❑NO PRI;-APPI.ICA IION ElYES 11:YES.PROVIDE COPY OF PLANNER'S NAME RECEIVED BY, TOTAL��tJ0AT0N=. PLANNING APPI.H ❑ NO PLANNING APPROVAL I.I.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. 1 have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws relatin "building ruction. I author' entatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRLD PLA ,CHECKtYFE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building OVER-THE-COUNTER ILDtNGPLAN REVIEW permit for new building. ❑ EXPRESS Q PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C] STANDARD C7 PtMUC WORKS forme if any Hazardous Materials are being used as part of this project. © LARGE PfREDEPT _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑ MAJOR Q vrq �t+ls>rwxs�tiststCl D i�riVlxc>NI�rAL xALTx B1dgApp_20I Ldoe revised 03/16/11