11060111 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19944 PORTAL PLZ CONTRACTOR:KRT INC PERMIT NO: 1106011 t
OWNER'S NAME: RUSSELL SMITH 21001 SAN RAMON VALLEY BLVD DATE ISSUED:06/16/2011
OD""ER'S PHONE: 4082521249 SAN RAMON,CA 94583 PHONE NO:(925)556-0632
G LICENSED CONTRACTOR'S DECLARATIONr—
/� BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class s C J Li,.# �'� 1 d 8
MECH F RESIDENTIAL� COMMERCIAL�
Contractor ' Date L I•—)
I 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
REROOFING
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
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:36945024.00 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: Date: " L f
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
1 have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
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 comply with such provisions or this permit shall be deemed revoked. Own nt r• ed gent 1 t
Date: LJ 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 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,
C 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.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 27 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36945024 . 00
DATE ISSUED. . . . . . . : 06/16/2011
RECEIPT #. . . . . . . . . : BS000013792
REFERENCE ID # . . . : 11060111
SITE ADDRESS . . . . . : 19944 PORTAL PLZ
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : RUSSELL SMITH
ADDRESS . . . . . . . . . . : 1700 WALNUT ST #11B
CITY/STATE/ZIP . . . : PHILADELPHIA, PA 19103
RECEIVED FROM . . . . : K.R.T. , INC.
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: DATE: 06/14/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$1,800
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex lex PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK remove and replace clear story window to facilitate reroofing
SCOPE
ELI
NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the Det or addn7 info.
FEE ITEMS (Fee Resolution 09-051 E 1.110) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Window/Sliding Glass Door
Suppl.PC Fee: (F) Reg. 0 OT FO.0 1 hrs $0.00 $380.00 1 WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp.Fee-0 Reg. 0 OT r0_,01hrs $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 0 No $0.00
Planning Fee: $0.00 Select a Non-Residential
Building or Structure 0
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg,Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $1.50 $380.00 TOTAL FEE: 1 $381.50
Revised: 04/29/2011
CONSTRUCTION PERMIT APPLICATION \
is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION`
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINtO (408)777-3228• FAX(408)777-3333•build ingacupertino.org
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT;9
PROJECT ADDRESS PN# , `�
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OWNER NAME, PHO E-MAIL
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STREET ADDRESS CI , STATE,ZIP FAX
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CONTACT NAME PHONE E-MAIL
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STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME T T LICENSE NUMBER s t t LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL �y
K i T 6 C, ! +RT=n/c a sBc�wQs►4. !� (' FAX
STREET ADDRESS `, �i CI Y STATE ZIP PHONE
x11001 SamRAMo� V�1(1E9 ✓� �T'�S� 6 MoN 5$ da'S-S5 0 (.3.2—
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
Cf fL$To2 5 �'pa 0 't''t>
!FA 4S L- c e (moo 4= R4c�L_.A c-4—
EXISTING
EEXISTING USE PROPOSED USE CONSTR.TYPE M STORIES O CE SE Y
D VALUATION
1 S
EXISTG NEW FLOOR DEMO TOTAL ` y
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREADECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: El DETACH
--- ❑ ATTACH
a nul I,I.ING]NIT c IS A SECOND LIN IT ❑ SECOND STORY ❑Y,S
BEING ADDED".' ❑NO ADDITION- ❑NO
PRT,-APPLICATION ❑ YLs IF YLS.PROVIDE COPY Or Pi.A,NNFR s NI NW, RECEIVEDBY" / TOT L VALUAT
PI.ANNIN(.;APDL H ❑ No PLANNING APPROVAL LTA I'LR c -..J/
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 Thavereadthis
application and the information 1 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 relating to uilding construction. I authorizet1&==14ves of Cupertino to enter the ab ve-idel tified property for inspection purposes.
Signature of Applicant/Agent: L ?pVU
Date:
SUPPLEMENTAL INFORMATION REQUIRED PLAN CRECK TYPE ROUTING SLIP
_ New SFD or Multifamily dwellings: Apply for demolition permit for 11 oveR-Tx><couNTER ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
fomn if any Hazardous Materials are being used as part of this project.
❑ LARGE ❑ UE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ iHA1UR Q SANITARVSEWERDSTRrCT
submittal of Building Permit application. -
❑ E,tMRONMENTAL IWALTIF
BldgApp_2011.doc revised 03/16/11