10060123 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19810 PORTAL PLZ CON TRACTOR:KRT INC PERMIT NO: 10060123
OWNER'S NAME: ALLA ROZENVASSER 21001 SAN RAMON VALLEY BLVD DATE ISSUED:06/21/2010
VNER'S PHONE: 4082534169
SATE RAMON,CA 94583 PHONE NO:(925)556-0632
LICENSED CONTRACTOR'S DECL111ARATION BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r
License Class Lic.#� 'J`7 v MECH r— RESIDENTIAL r— COMMERCIAL
Contractor Date
JOB DESCRIPTION: REPLACE ROOF WINDOW SHRINK OPENING TO
I hereby affirm that I am licensed under the provisions of Chapter 9 ACC 3MIDATE
(commencing with Section 7000)of Division 3 of the Business&Professions NEVI ROOF FLASHING INSTALL NEW SIDING&TRIM LIKE
Code and that my license is in full force and effect. FOR LIKE
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 Valuation $1600
performance of the work for which this permit is issued. Sq.14't Floor Area:
1 have and will maintain Worker's Compensation Insurance,as provide by
Section 3700 of the Labor Code,for the performance of the work f i this APP i Number:36946042.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Isstied by Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations e e Cupertino Municipal Code,Section
9.18.
/ / RE-ROOFS:
Signature + ate V l�L All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
LJ O ER-BUILDER DECLARATION Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of Sig iature of Applicant:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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,
Business&Professions Code)
HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three ma intain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: He alth&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's m:terial. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air ality Management District I
performance of the work for which this permit is issued. wi 1 maintain compliance with the Cupertino Mu ici I Code,Chapter 9.12 and
the Health&Safety Code,Sectio"5533a1 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 O�vner or authorized agent: ate
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
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 I t ereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION L,!nder's Address
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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
•mnify and keep harmless the City of Cupertino against liabilities,judgments,
.its,and expenses which may accrue against said City in consequence of the I inderstand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section L censed Professional
9.18.
Signature Date
CITY OF CUPERTINO
4 ITEMS OF 40 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 3694642 . 00
DATE ISSUED. . . . . . . : 06/21 /2010
RECEIPT #. . . . . . . . . : BS000 )10668
REFERENCE ID # . . . : 10060123
SITE ADDRESS 19810 PORTAL PLZ
SUBDIVISION . . . . . .
CITY CUPER7INO
IMPACT AREA . . . . . .
OWNER ALLA LOZENVASSER
ADDRESS 19810 PORTAL PLZ
CITY/STATE/ZIP CUPERIaNO, CA 95014
RECEIVED FROM . . . . : KRT ITC-GARY PIRDDY
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, 600 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 600 . 00 0 .50 0 . 00 0 .50 0 . 00
1STPLNCK HOURS 1 .00 126 . 00 0 . 00 126 . 00 0 .00
1WINREP EACH 8 1 . 00 38 . 00 0 . 00 38 . 00 0 . 00
TOTAL PERMIT
----- ----- ---------
- ---------- ----------
155 . 50 0 . 00 165 .50 0 . 00
CITY'OF
CITY OF CU13ERTINO
GENERAL BUILDING
C U P E RT I N a PERMIT APPLICATION FORM
00123
APN # Date:
�+ a . a�
Building Address: /98ltg o2TAL- FLA Z4
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work on! Yes ❑ Nof es, irovide letter from HOA
Owner's Name: A CtA MpZ C-5�-N VA 55C:�'R Phone #:dog �!6o?
Contractor: p<R r (NC., Phone: 4A15 - 1554.-D(632-
Fax:
o32-
Fax: 5A-PACS
Contractor License #:
Cupertino Business License #:
Contact: Ktg�4 'CRS- Phone: 't2-15 -5-40
883
Fax:
Residential Commercial ❑
Job Description: R&pi kCC3 - C- kCi r-o P- Lt kC Rao F W
sovti"k 019CSN its T'o A Cr-CrWN LpaT(S N&U-r �aot� F��st1 NGS
1 QSTALL t tC*tas 5L0ING A mw\ - Ll kcg l' L'l
Building Permit Info:
Bldg C�--- Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/VI/V-A ❑ II/VI B, IV-HT, V-B [}._-
Valuation: f/foo• ap Square Footage:
Project Size: Express �t dard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
'oints Achieved:
1 For help, contact Build it Green at www.builditgreen.o r
Revised 07/14/09
CITY OF
CITY OF CUPERTINO
GENERAL BUILDIN(z APPLICATION
CUPERTINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applical ions (up to 400 sf) B
additional stucco application
e 1WINREP Replacement windows/slidingglass B
door ea 8 windows
1 WINMEWSTR New Window-:tructural shear B
wall/masonry ncludes plan ck fee
1 EPERMITFEE Electrical Perrr it Fee E
1MPERMITFEE Mechanical Pe:-mit Fee M
1 PPERMITFEE Plumbing Pern lit Fee P
1 ELCPLNCK Stand Alone E.ectric Pln Ck(hourly) E
1 MECPLNCK Stand Alone N lecha tical ?In Ck (hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
I 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B
when not over counter hourly-stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
1 TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel & Documentation B
1BUSLIC Business Lic(nse B
5of5