10060125 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19960 PORTAL PLZ CW TRACTOR:KRT INC PERMIT NO: 10060125
OWNER'S NAME: HENRY SHIN 210)1 SAN RAMON VALLEY BLVD DATE ISSUED:06/21/2010
ER'S PHONE: 4082961520 SAN RAMON,CA 94583 PHONE NO:(925)556-0632
LICENSED CONTRACTOR'S DECLARATIONr
O MECH BUIDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# T5� RESIDENTIAL COMMERCIAL r—
Contractor t Y
�Q t &,- Date 1'_/ ,�j� 0 l l/
I herebyaffirm that I am licensed under the provisions of Cha ter 9 JOB DESCRIPTION: REPLACE ROOF WINDOW SHRINK OPENING TO
p ACC DMIDATE
(commencing with Section 7000)of Division 3 of the Business&Professions NEVA'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
performance of the work for which this permit is issued. Sq.'.4 Floor Area: Valuation:$1600
I have and will maintain Worker's Compensation Insurance,as provided fo y
Section 3700 of the Labor Code,for the performance of the workfor h is APP Number:36945033.00 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
granting of this permit. Additionally,the applicant understands and will comply Issi ed b Date:
with all non-point source regulati s r the Cupertino Municipal Code,Section
9.18. `4V —
p '/10
RE-ROOFS:
Signature Date cs All i oofs shall be inspected prior to any roofing material being installed.If a roof is
Inst;Bled without first obtaining an inspection,I agree to remove all new materials for
insp.-ction.
rJ OWNER-BUILDER DECLARATION
Sigr ature of Applicant: Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I ho ve read the hazardous materials requirements under Chapter 6.95 of the
Cal fornia Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Hei Ith&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's marerial. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air -ontaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino MJa125534.l Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 25505, 5
Section 3700 of the Labor Code,for the performance of the work for which thisaqOwneror authorized agent: e:
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. wor k's for which this permit is issued(Sec.3097,Civ C.)
Ler der's Name
APPLICANT CERTIFICATION Lender'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
noon the above mentioned property for inspection purposes.(We)agree to save
.mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
—is,and expenses which may accrue against said City in consequence of the I ur derstand 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 Lic rased Professional
9.18.
Signature Date
CITY OF CUPERTINO
4 ITEMS OF 40 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lost :
APN . . . . . . . . : 369450:43 . 00
DATE ISSUED. . . . . . . : 06/21/2010
RECEIPT #. . . . . . . . • : BS0000:_0668
REFERENCE ID # . . . : 10060125
SITE ADDRESS . . . . . : 19960 :?ORTAL PLZ
SUBDIVISION . . . . . . .
CITY CUPERT:CNO
IMPACT AREA . . . . . . .
OWNER HENRY ;SHIN
ADDRESS . . . . . . . . . . : 19960 :?ORTAL PLZ
CITY/STATE/ZIP . . . : CUPERTCNO, CA 95014-3365
RECEIVED FROM . . . . : KRT INC-GARY PIRDDY
CONTRACTOR . . . . . . . : KENNET:3 R TROUT LIC # 30426
COMPANY . . . . . . . . . . . KRT INC
ADDRESS . . . . . . . . . . : 21001 3AN RAMON VALLEY BLVD
CITY/STATE/ZIP . . . : SAN RA40N, CA 94583
TELEPHONE . . . . . . . . : (925) 556-0632
FEE ID UNIT QUANTITY AMOUJT 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 1226 . 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
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 1, 655 . 00 MC
---------------
TOTAL RECEIPT 1, 655 . 00
CITY OF
CITY OF CUPERTINO
GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
I Moo I25-
APN # Date:
3(c� q S b a3 .00
��l��o
Building Address: /qg�v D paar A L 64-24
Mailing Address (if different from,building address):
� *�4?�q t-'-1 C4-W(A2D ASA(- sot sFrA C c.a(4A ICA , 9'
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work only) Yes ❑ No off yes, provide letter from HOA
Owner's Name: c4�N R"f 5 � Phon qo S ��` ! a a
Contractor: p<p,T NC., Phone: qA 5 - 55 G-o!0 3 2
Fax: 5A- AcS
Contractor License #: �r,544?68
Cupertino Business License #:
Contact: KtgO-4 TRaLrr Phone: `tZS
Fax:
Residential Commercial ❑
Job Description: Rip,Acr, , (Aa r,.R- Lt kC - Roo r W&N OO c �r
SaERiN,R. 019csN tNG TD r4GCv��riDLL- f�� &'I' fux pyao r
1 Q STALL A C-rt�.s $�d ll�t Cz a6 Ri'M • Lt res l�2
Building Permit Info:
Bldg C5—' Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-13 ❑ II/IIIN-A ❑ 1I/I11 B, IV-HT, V-B [�J-- V— I
Valuation: #//�Bo. ap Square Footage:
Project Size: Express [T'- Standard ❑ 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:
For help, contact Build it Green at www.builditgreen.or
Revised 07/14/09
CITY OF
CITY OF CUP'ERTINO
GENERAL BUILDING APPLICATION
CUPERTINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
1 ,9 additional stucc a application
Y 1� oo 1 WINREP Replacement w ndows/sliding glass B
door ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry includes plan ck fee
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone El;ctric Pln Ck (hourly) E
1 MECPLNCK Stand Alone M-1chanical Pln Ck(hrly) M
1PLMBLNCK Stand Alone Pl-nnbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
I 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
/ 1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Trave & Documentation B
1 BUSLIC Busines, Lien se B
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