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12030123CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR OWNER'S NAME: KORET FOUNDATION OWNER'S PBONF.: 4082530200 ❑ LICENSED CONfRACfOR'S DECLARA'T'ION License Class Lic. N Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 71111(1) of DI\'1x1111 3 of the Business J Professions Code and thal my license is in full force and effect. hereby affirm under penalty of perjury one of the following aro 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 perfomtance 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 die performance of Ore work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application mid state that the above information is correct. I agree to comply with all city and county ordinances yid store laws relating to building construction, mid 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, costs, and expenses which may acerae against said City in consequence of die granting of this permit. Additionally, the applicant understaurds mid will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date IpV OWNER -BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for one of the follmriitg aro reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, mid the structure is not intended or ollcred for sale (Sec.7044, Business S Professions Code) I, as owner of the property,anm exclusively contracting with licensed contractors to construct the project(Sec.7044, Business K Professions Code). hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Ceti ifixate of Consent to self insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for tine 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, Ibr the perfommanee of the work for which this permit is issued. I certify that in the perfomnance of die work for which this permit is issued, I shall not employ any person in ally numner so as to become subject to die Worker's Compensation laws of California, If, after makingthis certificate ofexemption.1 become subject to the Worker's Compensation provisions of the Labor Code, I must f anhwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTI FICAIION I certify that I have read this application and slate that the above inlnmration is correct. I agree to comply with all oily and county ordinances and suite 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, costs, and expenses %'Inch may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regutatiams per the Cupertino Municipal Code, Section 9.18. / CONPRACI.OR: KORET FOUNDATION PERMIT NO: 12030123 1050 RALSTON RD DA'Z'E ISSUED: 0323/2012 BELMONr. CA 94002-1143 PIIDNE NO: 131JILDING PERMIT INFO: BLDG r ELECT r, PLUMB r' AIECII 1- RESIDENTIAL r COMMERCIAL r - .JOB DESCRIPTION: APT215 - WASf1ER/DRYER HOOKUP Sq. Ft Floor Arca: I Valuation: $500 ARV Number: 32609041.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued hy: ��/✓ /7-/ � Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining all inspection. I agree to remove all new materials fbr Inspection. Signature of Applicant: Date: ALL, ROOF COVERINGS TO BE CLASS "A" OR BE'ITER IIA%ARDOUS MATERIALS DISCLOSURE I hnve rend the hazardous materials requirements under Chapter 6.95 of the California Ilealth S Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Nlunicipal Code, Chapter 9.12 and the Health R Safety Code, Section 25532(x) should I stare or handle llareArdmis material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Buy Area Air Quality Managemcnl District I will maintain compliance with the Cupertino Alunicipal Code. Chapter 9.12 and the Iealth S Safety Code. Sections X5505. 25533, and 25534. Ow nergV authoriz ager V .� Y.Y )ate:�� CONSTRUC71ON LENDING AGENCY I hereby affirm that there is a construction lending agency fertile performance of oork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCIIITECf•S DECLARA'T'ION I understand my plmis shall be used as public records. Licensed 6 -ITEMS OF 12 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609041.00 DATE ISSUED.......: 03/23/2012 RECEIPT 4.........: SS000016348 REFERENCE ID # ...: 12030123 SITE ADDRESS .....: 20975 VALLEY GREEN DR SUBDIVISION ......: CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: KORET FOUNDATION ADDRESS ..........: 1050 RALSTON RD CITY/STATE/ZIP ...: BELMONT, CA 94002-2243 RECEIVED FROM ....: VILLAGES AT CUPERTI CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: KORET FOUNDATION ADDRESS ..........: 1050 RALSTON RD CITY/STATE/ZIP ...: BELMONT, CA 94002-2243 TELEPHONE ........: OPERATOR: patg COPY # : 1 FEE ID ---------- UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL -ADMIN --------' HOURS ------ 1.00 ---------- 41.00 0.00 ------- 41.00 ------ --- 0.00 1BAPPLOTHE NO OF APPLIAN 2.00 130.00 0.00 130.00 0.00 1BCBSC VALUATION 500.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 500.00 0.50 0.00 0.50 0.00 1MPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00 TOTAL PERMIT ---------- 260.50 ---------- 0.00 ---------- 260.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 521.00 --------------- 521.00 VOICE ID DESCRIPTION -------- ---------' ----------- 301 ROUGH PLUMBING REFERENCE NUMBER ------------- #2628 VOICE ID DESCRIPTION -------- ---- ---------------- 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL OWNER -BUILDER DISCLOSURE FORM COtdISUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 9501473255 (408) 777-3228 • FAX (408) 777-3333 • buildinaQ6uoarino.ora CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS Z 0 9 . c• ^ /• �/51 APN 3,Z)6190 / 0 lJ OWNER NAME /i /ZET 101; 9Tid OWNER ADDRESS DESCRIPTION OF WORK: We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of --your responsibilities and possible risk -you -may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. read and initial each statement below to signify you understand or verify this information.) 5 1/ 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held, liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowners insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. �& 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. S [/ 3.1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. S ✓/ 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 51b. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 5 1/ 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by tfiese laws may subject me to serious financial risk. �7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. �Z& 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OirnerBuilderForsW 2010.doc revised 04/14/10 5 1/9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand'I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or v✓vrw.csib.ca.gov for more information about licensed contractors. 5-1/ 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. ,�Vl 11� I agree that, as the party legally and'nnancially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. S L 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does riot have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY ' (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.). Lender Name:Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to'be presented when the permit is issued to verify the property owner's si na ure. Property Owner's Signature:/y G Date: �—� =-------------------------`-----------=--- -------------------- ------- ---------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding ttie Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: 100, I declare under penalty of perjury that 1 am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderFonn 2010.doc revised 04/14/10 CITY OF CUPERTINO FEE ESTIMATOR -BUILDING DIVISION APPLIANCE/ EQUIP TYPE ADDRFSS: PboaG. Plan Check DATE: REVIEWED BY: BP FEES APN: QP#: 'VALUATION: $500 *T'liRMIT TYPE: Mechanical Permit 2 PLAN CIIECK TYPE: Alteration / Addition / Repair PRIMARY SFD Or Duplex USE: PENTAMATION 1RMAP1 PERMIT TYPE: WORK Snppl. hisp.Fee SCOPE APPLIANCE/ EQUIP TYPE FEE ID PboaG. Plan Check QTY UNI'T'S BP FEES Flea Permit Fee: Other Appliance/Equip 1BAPPLOT Olhea l.'ler.. hr.xp. 2 # $130 permit Fee: Snppl. hisp.Fee PML' Unit Fee: $130.00 PME Permit Fee: $44.00 Cnnsiruclion Tac: Administrative Fee: gD,t4/N $41.00 Work Without Permit? 0 Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRA I DOC $130.00 Strong Motion Fee: IUSEISHICR NNE: This estiautte does not include fees due to other Departments (i.e. Planning, Public li'orAs, Fire, Slit titaly Sewer District, School District, etch These fees' ore based on the arelininarr infortnation available and are otdr an ectintnte. Contact the Dent for adtht'l into. FEE ITEMS (Fce Resolution 11-053 E(f 7/1/l /) b9ech. Plan Check 0.0 hrs $0.00 PboaG. Plan Check Flee. Phar Check Mech. Permit Fee: IMPF.RHIT Plumb. Permit Fee: Flea Permit Fee: Other Mech. Insp. 0.0 hrs $44.00 01her Pluorli hap. Olhea l.'ler.. hr.xp. Af •ch. Imp. Fee: P/oatb. Insp. Fee: Eler. /AV). Fee: NNE: This estiautte does not include fees due to other Departments (i.e. Planning, Public li'orAs, Fire, Slit titaly Sewer District, School District, etch These fees' ore based on the arelininarr infortnation available and are otdr an ectintnte. Contact the Dent for adtht'l into. FEE ITEMS (Fce Resolution 11-053 E(f 7/1/l /) FEE QTY/FEE MISC ITEMS Plan Cheat- Fee: Suppl. PC Fee PME Plan Check: $0.00 permit Fee: Snppl. hisp.Fee PML' Unit Fee: $130.00 PME Permit Fee: $44.00 Cnnsiruclion Tac: Administrative Fee: gD,t4/N $41.00 Work Without Permit? 0 Yes 0 No $0.00 Ael aneed Planning Fetes: Travel Documentation Fee: ITRA I DOC $44.00 Strong Motion Fee: IUSEISHICR $0.50 Select an Administrative Item Blclg Stds Commission Fee: IUCUSC $1.00 SUBTOTALS: $260.50 $0.00 TOTAL FEE: $260.50 Revised: 1/19/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT •BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 _ rGUPEEiS`1N4 (408) 777-3228 • FAX (408) 777-3333 • buildingdl cuoertino ora I I NFW r nNCTRirf qnw n ennrrrnu 11 f1 _ '. B1dgApp 2011.doc revised 03/16/11 PAOIECr ADDRES^ ' .L19 5, // I' ZI•�./ IAPN r O tq -L — --- •. OWNERNAME i //4 PHONE E-MAILro STREET ADDRESS Z S �/ .c i e Jar, Cr1Y, 5T Z '�r� ���i/l ' � % /.� FAX CONTACT NAME ry PHO E -MAB. S*1TEm ADDRESS C Ar'E, ZIP FAX ? / OWNER ❑ owNER.Bu=ER ❑ OWNERAGENr ❑ C0N7RACr0R ❑CONTRACrORAGENr ❑ ARCHITECT ❑ENGR.'FER ❑ DEVII_,OPER ❑ TENANT CONTRACTORNA-Z,M- LICENSEN[R.[BER - 'u cTYPE BUR LICO . COW ANY NAME E -gyp FAX STREET ADDRESS— N .STATE. ZIP P90NE ARC=CTIENGIT(EFANAME LICENSE NIR.faER - Bus. LILY , COMPA.W XAME E_NIAR,' FAX STREET ADDRESS CITY. STATE, Z@ PHONE DESCRIPTION OF WORE ' va-z-A EcTrINGUSE � - PROPOSEDmE CONS17i. MORM E=G NEW F1.0ca DEMO TOTAL �y �'�?,'� y.zj AREA AREA AREA P-.L'^�4'aS Mau NETAREA 1.-1 BATHROOM r -s m KR'Qh2t OTPB-g Y a .REMODEL AREA REMODEL AREA REMODEL AREA. ��ywT {� }yJl#s ^+� PORCH AREA DECX AREA ; ' TOTAL➢ELK/FORCE AREA , GARAGE ARE pErA� f �, in A yi iz r5�.8 MEN /D0.'StH10 UNnS MA5 =M1JNrr ❑ M sEcoMsroRY Yp �F )j- HE'NtGADHEIIi ❑ NJ AO])r]'tC(ii No •" `~ li: S' N`^ S•�t`, Frt./s }� 5• N h ❑ HI' 66 �, PAa-APPLIGr1pN ❑TE9 bYF$PROVaff CUPYOF PIANMA'S NAFE RtEELYFD9Y Z_ ❑ ... iR N.AM6VO APPt/ No PLS}A'Wp AP.'AOVAL.LEtrfl[ '^S t/- -d . By my signature below, I certfy to each of the following: I am the property owner or authorized agent to act on the property owner's behalf.- I have read this application and the infoimatlbn I have provided is correct I have r ad the Deription of Work add verify it is accurate. I agree m comply with all applicable local ' ord-mances and state laws relating to b g corssgnrion I au; riza represensctatives of Cupertino to enttr the ab�o7ve-idezuified property, for inspection proposes. .Signature ofApplicanNAgent C / Date: ,.. .._.. S'UPPL, 2v 14'1AL INFORIvfATlON RE - - New SFD or Multifamily dwellings: Apply for demolition permt for ©•}VY�A 'Hb ®/".tgG136 existing building(s). Demolition permit is required prior to issuance ofbuildmg \REN permit for new building. t, �O; e s m **¢'' ., tyl,_ t- FIV r,yh•. �tA �nu"iBi Rt Yom• _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project • !S LAR(, r - r ,r. ti Copy of Planning Approval Letter or Meeting with Planning prior to _ •;.-ye'�'s'�yr� submittal of Building Permit application. L"soR +Rr N;DTRr�-r c� '. B1dgApp 2011.doc revised 03/16/11