Loading...
12030122CITY OF CUPERTINO BUILDING PERMIT RUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRACI'OR: KOI0:T FOUNDATION PFR91IT NO: 12030122 OWNER'S NAMEI: KORETI:OUNDATION 1050 RALSTON RD DATE ISSUED: 03232012 OWNER'S PHONE: 4082530200 BELMONT. G\ 94002-2243 PHONE NO: ❑ I.ICI'.NSED CONTRACTOR'S DECLARATION r r r — BUILDING PF;Rh11T INFO: BLDG ELECT PLUMB License Class Lic.q r r rl p1ECH RESIDENTIAL COMMERCIAL Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: AP'r 288 -ADD WASHER/DRYER HOOKUPS (commencing with lection 7000) of Division 3 of (he Business x Professions Code and Hun my license is in full force and effect. 1 hereby affirm under penally 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 (he Labor Code, for the performance of the work for which this permit is issued. 1 have and will. maintain Worker's Compensation Insurance, as provided for by Sq. FI Floor Area: Valuation: $500 Section 3700 of the labor Codc, Ibr the performance of dlc work forwhich this APN Number: 32609041.00 Occupancy Type: permit is issued. AI'I'LIG\N'I' CEK'fI PIG\'PION I certify that I have read this application laid stale that the above information is correct. l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building constnretien, and hereby authorize representatives of this city to enter upon the above mentioned property ter inspection purposes. (We) agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City ofCupenineagainst liabilities, judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs, and expenses which 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 regulations per the Cupertino Municipal Code, Secti"i �N/ Issued by: �Aell 1-47G/7 Date: .3 9.18., , Signature Dale RI ROOI�S: All reaps shall he inspected prior to any roofing material being installed. If a roof is {`may OWNER -BUILDER DECLARATION V -"- installed without first obtaining an inspection, I agree to remove all new materials for I hereby offrrm that Iran exempt from the Conlraelor's License Lav fur one of inspectioin, the following two reasons: I, az owner of the property, or my employees With wages u their sole compensation, Signature of AppliclnC Date: will do the work, and the structure is not intended or offered for sale (Sec.7044, Business R Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to AL1. ROOF COVERINGS TO BE CLASS "A" OR HEATER construct the project (Sce.7044, Business & Professions Code). hereby affirm under penally of perjureone of the following three DA7.ARDOIIS MATERIALS DISCLOSURE declarations: 1 linNe read (he hazardous materials requirements under Chapter 6.95 of the I have and will maintain it Certificate of Consent to self -insure for Worker's California (health S Safely Cade, Sections 25505, 25533, and 25534. 1 will maintain Compensation, as provided for by Section 370001 -the Lahor Cade, for the compliance with the Cupertino Municipal Code, Chapter 9.12 and the llcalth S performance of the work for which this permit is issued. Safety Code. Section 25532(x) should I store or handle hazardous material. I have and Will maintain Workers Compensation Insurance, as provided for by Additionally. should I use equipment or de\'Ices which Poll( hazardlms air Section 3700 of the labor Code, for the perfimnance ofthe work Ibr which this contaminant, as defined by the HwyArea Air Quality \lanagenhcni District 1 will permit Is Issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 unit ale I cenily that in the performance ol'dlc 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 Oo ns;s;.or amhori .ed igen . Compensation laws ol'Calitomia. If, after making this certificate of exemption, 1 - L Date: 2- become subject to the Worker's Compensation provisions of the Labor Code, I must - fonhwith connply With such provisions or this permit shall be deemed revoked CONSTRUCIlON LENDING AGENCI' I hereby atfmn that there is a construction lending agency for the performance of work's Al'I'LIG\N'1' CFR'fIFICA'I'ION for which this permit is issued (Sec. 3097, Civ C.) I certify that I have read this application and state that the above infomnation is Lender's Name :orrecl. 1 agree to comply wvilh all city and county ordimmces :rad stale laws relating '.o building construction, and hereby authorize representatives of this city to enter Lender's Address ipon the above mentioned property for inspection purposes. (We) agree to save ndemnlfy and keep harmless ale City ol'Cupertlao against liabilities, judgments, :osts, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ;ranting of this permit. Additionally, tile applicant understands and will comply I understand my plans shall be used as public records. xith all non -point source regulatinls per the Cupertino Municipal Code, Section 3.18. � Licensed Professimud iignatid IJlac_��%�� M CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORREAVENUE • CUPERTINO, CA 95014-3255 - - - (408)777-3 . 228 • FAX (408) 777-3333 • buildinaDcuDanino.ora Dear Property, Owner(s):_ An application for a building permit has 6een'submitted in your name listing yourself as the builder of the property •�- improvements specified at: SITE ADDRESS S: / / APN D BP,. OWNER Nn� N OWNERADDRESS (/ DESCRIPTION OF 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 incucby 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. =WLEDGMENT AND VERIFICATION OF INFORMATION - Please read and initial each statement below to signify you understand or verify this information.) 15111. 1 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 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 homeowner's 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. 2. 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. 5_13I. t 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 Fisk by hiring a licensed Contractor and having the permit fled in his or her name instead of my own. �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. 5-1—A. 1 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. L6. 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." 1 also understand my failure to abide by these laws may subject me toosehous financial risk. • _U 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 generalbuilding Contractor. �WB. I understand as an Owner -Builder if I sell the property for which this permit is issued, ['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. OwnerBuilderForm 2010.doc revised 04114/10 f9: 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.Benent Payments, and the California Division of Industrial Accidents. I also understand I may contact the Cal'rornia Contractors' State License Board (CSLB) at 1-800-321,, CSLB (2752) or wwwicslb.ca.gov for, more information about licensed contractors. SV 10: I am aware of and consent to an Owner -Builder building permit applied forin my name, and understand that I am the party legally and financially responsible for proposedconstruction activity at the site address listed above. S. _.:; -: 11.•I•agree that, as,tfie patty legally and financiallyTesponsible for this proposed construction activity, Pwilfabide > = by all applicable laws,and requirements4hat govern Owner -Builders as well as employers- �/ 12. 1 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 not 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 Contractorsmaybe 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 j097 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 po vner's driver's license, form notarization, or other verification acceptable to the ity may be required to•be presented when the permit is issued to verify the propertyowner's si na ure: Property Owner's Signature: 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 the 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: Tel No I declare under penalty of perjury that I 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 venfy the property owner's signature. Property Owner's Signature: Date: O�. nerBuilderFarm 2010.doc revised 0;/19/10 WN���t CITY OF CUPERTINO 0 FEE ESTIMATOR -BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: Phod). Plon Chu DATE: REVIEWED BY: S APN: BP#: 'VALUATION: $500 *PERMIT TN'PE: Mechanical Permit # PLAN CR ECK TYPE: Alteration / Addition / Repair PRIMARI SFD or Duplex USE: Permit Fce. PENTAMATION 1 RMAP1 PERMIT TYPE: NYORI: SCOPE PME Unit Fee: APPLIANCE / EQUIP TYPE FEE ID Phod). Plon Chu QTY UNITS BP FEES F.lec. Pemtit Fee: Other Appliance/Equip 1BAPPLOT Other Flee. bnp. Ll I 2 # $130 Permit Fce. Supp/. 111sp Fee PME Unit Fee: $130.00 PME Permit Fee: $44.00 Crutsirnetion -Tax.- Tax:Administrative AdministrativeFee: 1ADM/N $41.00 Work Without Permit? 0 Yes (j) No $0.00 TOTALS: Travel Documentation Fee: ITRAPDOC $130.00 Strone Motion Fee: IBSF.ISMICR tvutt: ilei estimate (toes ant tachtAe fees due to other Deparlinents (i.e. Planting, Public Works. Fire, SanilarySewer District, School District, ele.). These fees are bate(/ on the Drelininarr information availahle and ora h, on rohatap Conr.Jrt he nrnr a,r..dd.. of i,.n, FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11) Mech. Plan Check 0.0 1 hrs $0.00 Phod). Plon Chu Elec, Plat Chuck Mech. Permit Fee: IMPERMIT Plumb. Pemtit Fee: F.lec. Pemtit Fee: Other Mech. Insp. 0.0 hrs $44.00 Ocher Phanh hrcp. E71 Other Flee. bnp. Ll I :1,fech. /nVo. Fee: Plumb. la,.p. Fee: glue. Ings. Fee: tvutt: ilei estimate (toes ant tachtAe fees due to other Deparlinents (i.e. Planting, Public Works. Fire, SanilarySewer District, School District, ele.). These fees are bate(/ on the Drelininarr information availahle and ora h, on rohatap Conr.Jrt he nrnr a,r..dd.. of i,.n, FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: SltppL PC Tee PM E Plan Check: $0.00 Permit Fce. Supp/. 111sp Fee PME Unit Fee: $130.00 PME Permit Fee: $44.00 Crutsirnetion -Tax.- Tax:Administrative AdministrativeFee: 1ADM/N $41.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Facs: Travel Documentation Fee: ITRAPDOC $44.00 Strone Motion Fee: IBSF.ISMICR $0.50 Select an Administrative Item Blde Stds Commission Fee: IRCBSC $1.00 SUBTOTALS: $260.50 $0.00 TOTAL FEE: 1 $260.50 Revised: 1/19/2012 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.........: BS000016348 REFERENCE ID # ...: 12030122 SITE ADDRESS .....: 20975 VALLEY GREEN DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: ADDRESS ..........: CITY/STATE/ZIP .... RECEIVED FROM ..... CONTRACTOR .......: COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... TELEPHONE ........: FEE ID UNIT 1ADMIN HOURS 1BAPPLOTHE NO OF APPLIAN 1BCBSC VALUATION 1BSEISMICR VALUATION 1MPERMITFE FLAT RATE 1TRAVDOC FLAT RATE KORET FOUNDATION 1050 RALSTON RD BELMONT, CA 94002-2243 VILLAGES AT CUPERTI LIC # *OWNER* KORET FOUNDATION 1050 RALSTON RD BELMONT, CA 94002-2243 QUANTITY 1.00 2.00 500.00 500.00 1.00 1.00 uurol i"M 41.00 130.00 1.00 0.50 44.00 44.00 PD -TO -DT 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL PERMIT : 260.50 0.00 OPERATOR: patg COPY # : 1 THIS REC 41.00 130.00 1.00 0.50 44.00 44.00 260.50 NEW BAL 0.00 0.00 0.00 0.00 0.00 0.00 CONSTRUCTION TION PERMIT APPLICATION. COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION, 1030 , 0 TORRE AVENUE - CUPERTINO, CA 95014-3256 CUPERTINO (408) 717-322.8 - FAX (408) 777-3333 - buildino0cuoertino.ora Id AW CONSTRU=N F-1 Ann=w F-1 F-1 Ems# __ ......--- -11` 1 PROJECrADDRESr, A-111' & /KOR'OWNER NAME ETDaWAL,PYO E-MAIL ST= ADDRESS Crry CCa'rrACT NAME E-MAIL loo— CrTY An, ZIP, /W OWNER D owmm-BITELDER 11 OWMRA= El..CONTNAtnos EIOO,,,,,CTORAGF,,,r C] ARMD`<a E] ENMqEEK El DEYELOPM El TDIANT CONTRACMXNA.MM: LlcENSE EX k I S Bus. LIC # 111AN11 E N[AIL FAX STREETADDRESS r, cryx, Crry, STATF 0 AXCHTIECTIENGB,MNAME LICENSE NUMBPk. BUS. LIC # COWANYNAIvM E-MAIL FAX slRPET ADDRESS C=. STATF ZIP PHONE DESCRIPTION OF WORK EXISURTGUSE PROPOSED m]s CONSTK TYPE 9 STORnas- R=Y SIM EXISTG MEWFLOM AREA DEMO AREA TOTAL NETAR11A yr IM_ 'BATHROOM RIW[ODEL AREA Krrc BEMODEL AREA OTHER REM DEL PORCI.AR�k B� TOTAL DECKNORQiAltzA, GkItAGEAR_-�_- 0 DETACH ❑ ATTACH f P�540 gli ".�N F%, El szc .=oRy g BEINGADDED, No On L11.1 Wal PPE -APPLICATION ❑ as rm.mcyroampycN PIaNNPR'SNA� .- ­.­ R.......... By my signature below, I certify to each of the following. I = the property owner or authorized agent to act on the property owner's behalf. -I have mad this application and the information I have provided is correct lhave ;Z�th iptlon of Work and verify it is aCctra' a. I agree to comply with all applicable local ordinances and state lam mlading to buil on=ctio I authorize e scrip �IA97 ; setnatives of Cupertino to enter the above -identified property. for inspection Purposes. 9 I Signature of Applicant/Agent: ............ C _2a Date:' SUPPIII ENTALINF ON REQUIRED, New 5FD or &ultifiimfly dwellings: Apply for demolition permit for t for existing buildi:ng(s). Demolition permit is required prior to issuance otbuilding of bAdm- permit for new building: . W-1-1 — 1 0.47 �© GiRl Commercial Bldgs: Provide a completed Hazardous Materials Disclosure "closure iorm a any Hazardous INTaterials are being used as part of this project. e. if NI RM Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. BldgApp_,2011.docrevised Oill6liI