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12010118 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 500 CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 12010118 DRIVE OWNER'S NAME: 20800 VALLEY GREEN DRIVE PO BOA 130156 DATE ISSUED:01/18/2012 OWNER'S PHONE: 4082530200 CARLSBAD,CA 92013-0156 PHONE NO: ❑ LICENSED CONTRACTOR'S(DECLARATION BUILDING PERIVIIT INFO: BLDG ELECT ' _. PLUMB License Class Lic.# yµµ, MECH' RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APT 500-WASHERIDRYER HOOKUP (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm tinder penalty of perjury one of the following two declarations: €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.Ft Floor Area: Valuation:$500 €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. APN Number:32609040.500 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upan the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against 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,Section Issued by; Date: / l 9.18. Signature Date RE-ROOFS: [� Obi NER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is i� installed without first obtaining an inspection,I agree to rennove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm tinder penalty of perjury-one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3760 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. 1 have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for tine performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will Sectio is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I Health&Safety Code,Sections 25505,25533,and 25.534. 1 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 O er or authorized age Compensation laws of(_'alifornia. If,after making this certificate of exemption,I4. Date: becorne 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnity and keep liamiless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 4.18. Licensed Professional Signatu Date OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• bui1dlna(�CUDerbno.orq 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 APN BP# / fDo / C OWNER NAME ' OWNER ADDRESS dzl=,=-.z 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. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) L/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 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. 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. 14. 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 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. 51,/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 these laws may subject me to serious financial risk. 5/7. 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. �/ 8. 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. OwnerBuilderFonn 2010.doc revised 04114/10 11 V'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 www.cslb.ca.gov for more information about licensed contractors. }V 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. A✓11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by,,alll applicable laws and requirements that govern Owner-Builders as well as employers. �V 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 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 cit may be required to be presented when the permit is issued to verify the property owner's si na re. Property Owner's Signature: 7t' Date: .r ---------------------------------------------------------------------- ---------------------------------------------------------------------- (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: Tel No Address of Authorized Agent: 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 verify the property owner's signature. Property Owner's Signature: Date: GYvnerBuilderForn? 2010.doc revised 04114/10 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32609040.500 DATE ISSUED. . . . . . . ; 01/18/2012 RECEIPT #. . . . . . . . . BS0000IS773 REFERENCE ID # . . . : 12010118 SITE ADDRESS . . . . . : 20800 VALLEY GREEN DR APT 500 SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER 20800 VALLEY GREEN DRIVE ADDRESS PO BOX 130156 CITY/STATE/ZIP . . . : CARLSBAD, CA 92013-0156 RECEIVED FROM . . . . : VILLAGES AT CUPERTI CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY 20800 VALLEY GREEN DRIVE ADDRESS PO BOX 130156 CITY/STATE/ZIP . . . : CARLSBAD, CA 92013-0156 TELEPHONE . . . . . . . . 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 AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 260. 50 #4020 --------------- TOTAL RECEIPT 260 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 301 ROUGH PLUMBING 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 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20800 valley green#500 DATE: 01/18/2012 REVIEWED BY: bobs. APN: BP#: VALUATION: $500 -1 PERNHT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY Multi-1=amil Dwellin Buildina is PENTAMATION 1 RMAP1 USE: Y g >3 Stories Q Yes Q No PERMIT TYPE: WORK W/D hook-up SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 1BAPPLOT 2 # $130 TOTALS: $130.00 N-tech.Plan Check hrs $0.00 LEI Meeh.Pemiit Fee: I MPERMIT Other It-tech. Insp. [E] hrs $44.00 NOTE: This estimate does not include fees due to other Departments(Le. Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These ees are based on the relinina in ormation available and are only an estimate. Contact the Dept or addh 7 info. FEE ITEMS 'f e:< <'c s raa f»a ;;-t)_ 'i//I I FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $130.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMIN $41.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 1BSEISMICR $0.50 Select an Administrative Item PIdj_ td ijn s'>ic ri Fie: IBCBSC $1.00 SUBTOTALS: $260.501 $0.00 TOTALFEE. F $260.50 Revised: 1/01/2012 . ........... CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 , (408)777-3228 FAX(408)777-33•building cDcuoertino.org ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DF-FF-RRFb QkGLIALPERMIT m PROJECT ADDRES:' ' APN# � OWYERNAME / `� f' � V � . PHO � E-MAIL .... STREET ADDRESS /j1^c 'e, 11 /W., 71A / F�� �/ r (✓ CONTACT NAME G ( N�/G PHO ` E-MAILi r� A O' STREET ADDRESS C STATE, Il' FAX i�r OWNER ❑ OWNER-BUILDER ❑ OWNERAGENr ❑ CONTRACrOR ❑CONTRACI-ORAGENT ❑-ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTORNAME" LICENSENUNMER. LICENSE TYPE BUS.LIC# COMPANY NAME A/� �Y^ EMAIL. FAX 4-,I� • - 1/ STREET ADDRESS + l•' �h ll STATE ZIP PHONE ARCHTTECT/ENGIlIMER NAME LICENSE NUMBER BUS.LIC# COMP ANY NAME E-MAIL' FAX ^ STREET ADDRESS CITY.STATE,ZIP PHONE DESCRIPTION OF WORK EXISTiNGUSE PROPOSED USE CONMR.TYPE #STORIES t4 a EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN OTHER .REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKNOR(H AREA GARAGE AREA:❑ DETACH . ❑ ATTACH /DWEILIlQG UNII'S IS ASECOND UNIT ❑YES - SECOPID STORY ❑YES BEINGADDED? ❑NO ADDITION? ❑NO PRE-APPLICATION ❑YEs IF YEs.PRovmE cOPYOF PLANNER'S NAME: PLANNINGAPPL/ ❑NO PLANNINGAPPROVALIErrER By my signature below,I certify to each of the following: I am the pr erty owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have rea the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b g con ion. I auth a representatives of Cupertino to entdr the above-identified/ /�property for inspection purposes. Signature of Applicant/Agent: r' ' Z� (� Date: ��/� � SUPPLEMENTAL'INFORMATIQN REQUI]E4l. . " New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance ofbuilding permit for new building. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project. _Copy of Planning Approval Letter or Meeting with Planning prior to x submittal of Building Permit application. R k : .. H Bld&4pp 2011.doc revised 03/16111