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12010179 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR CONTRACTOR:20800 VALLEY GREEN DRPERMIT NO: 12010179 OWNER'S NAME: 20800 VALLEY GREEN DR PO BOX 130156 DATE ISSUED:01/31/2012 OWNER'S PHONE: 4082530200 CARLSBAD,CA 92013-0156 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r--- I..._ a_._ BUILDING PERMIT INFO: BLDG ' ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:#485-WASHER/DRYER 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 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. Valuation:$500 Sq.Ft Floor Area: I 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:32609040.00 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 upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 1$0 DAYS OF PERMIT ISSUANCE OR indemnity 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: 9.18. Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 rernove all new materials for I hereby affirm that I am exempt from the C'ontractor'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) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct tine project(Sec.7044,Business&Professions Code). hereby affirm under 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 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work Tor which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I 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 the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance With the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner authorize agent•,.^ Compensation laws of California. If,after making this certificate of exemption,I `,i moi( `'� Date: become subject to the Worker's Compensation provisions of the Labor Code,I must torthwith 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 indemnify and keep harmless 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 regulatic€as per the Cupertino Municipal Code,Section 9.18. �' Licensed Professional Signature,, ✓ %-. Date �/' CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32609040 . 00 DATE ISSUED. . . . . . . : 01/31/2012 RECEIPT #. . . . . . . . • : ES000015876 REFERENCE ID # . . . : 12010179 SITE ADDRESS . . . . . : 20800 VALLEY GREEN DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : 20800 VALLEY GREEN DR ADDRESS . . . . . . . . . . : PO BOX 130156 CITY/STATE/ZIP . . . : CARLSBAD, CA 92013-0156 RECEIVED FROM . . . . ; VILLAGESATCUPERTINO CONTRACTOR LIC # *OWNER* COMPANY 20800 VALLEY GREEN DR ADDRESS PO BOX 130156 CITY/STATE/ZIP . . . : CARLSBAD, CA 92013-0156 TELEPHONE . . . . . . . . . FEE ID UNIT QUAPNTITY 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 #4044 --------------- 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: 20975 valley green dr#485 DATE: 01/31/2012 REVIEWED BY: bobs. APN: #: 'VALUATION: [$-500 AN C=HECK PL T' is It PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration Repair PRIMARY Buildinca is 0 PENTAMATION I RMAP1 I Multi-Family Dwelling Stories s (E) Na>3 Stories 0 Yes PERMIT TYPE: A [JSE: WORK W/D hook-ups SCOPE Mech.Plan Checko-o hrsF $0.00 Mech.Permit Fee: IMPFRA11T Other Mech.Insp. 0.0 hrs �$4 4.00 Lj NOTE; This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These fees are based on theprelinadina information available and are o!A an estimate. Contact the DeLor addh 7 in o. FEE ITEMS (],'ee Resohilion FEE QTY/FEE I MISC ITEMS Plan Clieck Fee: $0.00 2 # Mechanical Suppl. PC Fee: E) Reg. C) OTrs $0.00 $130.001 IBAPPLOT Other Appliance/Equip Iirs PME Plan Clieck: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg, 0 OT �hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 1 1 — Administrative Fee: 1ADMIN $41.00 Work Without Permit? Yes (D No $0.00 Advaticej PlaT11.1ing Fee: $0.00 Select a Non-Residential Building or Structure 0 Travel Documentation Fee: 1 TR,4 KDoc $44.00 14 Sjr�,)noLjotioti Fee: IBSEISMICR $0.50 Select an Administrative Item 131c1 Stds Commissloo_L_ee' IB_CB SC $1.00 SUBTOTALS: $130.50 $130-0A0 - TOTAL FEE: $260-501 Revised: 1/19/2012 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• build ing5cugertino.orq 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 APN BP ., OWNER NAME OWNER ADDRESS DESCRIPTION OF WORK: r714e /t �j 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.) �5_zi. 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. JG 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. 5U 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. 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. 2 1/ 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. 546. 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. 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. Y 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. a 4,7?e1"Buildel'Fo7-iii 2010.doc revised 04/14110 .U-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.csib.ca.gov for more information about licensed contractors. �V10. 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. 5 I/11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 5-6—/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 city may be required to be presented when the permit is issued to verify the property owner's si nature. 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: 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: Ohn7erBuilderFonn 2010.3oc revised 04114/10 31 -7q CONSTRUCTION PERMIT APPLICATION 0' COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO,CA 95014-3255 (408)7717-3228 • FAX(408)777-3333•building aacupertino.org CUPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION I-E ❑ REVISION/DEFERRED ORIGIIv'AL PERMIT _ PROJECT ADD PN' :32� / . �, -840 iml . PHONE E-MAIL• qJ v v S�QO � s "[ / j CITY STATE ZIPFAX S-V/` { TA NAME ' / ` PHONE E-MA Z� h STREET ADDRESS �+ CITY,STATE,ZIP FAX G G //e! �� U OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACrOR ❑CONTRACTOR AGENT 11 ARCHITECT ❑ENGINEERR ❑ DEVELOPER ❑TENANT CONTRACTORNAME LI S LICro E BUS.LIC# COMP ANY NAME E-MAIL FAX STREET ADDRESS ,STATE,ZIP PHONE 5noIt i .1• y ARCHITECT/ENGINEERNAME LICENSE NUMBER BUS.LIC# COMP ANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK , r V'e �u EXISTINGUSE PROPOSED MCONSTR TYPE #STORIES 1bFTG S Q EXISTG NEWFLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORM AREA GARAGE AREA:❑ DETACH . ❑ ATTACH RDWEI.LINGUNIM IS ASECOND UMT YES SECOM STORY YES BEINGADDED? ❑NO ADDITION? ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF PLANNER'S PLANNNG APPL K ❑NO PLANNING APPROVAL.LETTER By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's b alf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I au orize representatives of Cupertino to enter the abbove-identified property.for inspection purposes. Signature of Applicant/Agent: Date: SVPPLEIv ENTALTNFORIVIATION REQ . . D . 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 submittal of Building Permit application. Bldg�4pp 2011.doc revised 03/16/11