Loading...
12020090CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20875 VALLEY GREEN DR OWNER'S NAME: KORET FOUNDATION OWNER'S PHONE: 4082530200 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic.# Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. t 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. I have and will maintain Worker's Compensation insurance, m provided for by Section 3700 of the Labor Code, t61- the performance of the work for which this permit is issued. 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 to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnity 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 with all non -point source regulations per the Cupertino Municipal Code, Sectirxt 9.18. Signature Date CONTRACTOR: KORET FOUNDATION 1050 RALSTON RD BELMONT, CA 94002 PERMIT NO: 12020090 DATE ISSUED: 02/21/2012 PHONE NO: BUILDING PERMIT INFO: BLDG' ELECT PLUMB - �.:...:: t MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: APT 27 - WASHER DRYER HOOKUP Sq. Ft Floor Area: Valuation: $500 APN Number: 32609064.00 Occupancy Type: d OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the C'ontractor's License Law for one of the following two reasons: 1. 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I herebv affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Workers Compensation, as provided for by Section 3700 of the Labor Code, for the 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, fitr the performance of the work for which this 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 becorne subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become 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. 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 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 «f 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 with all non -point source regulations peF the Cupertino Municipal Code, Section 9.18. / Signature Gni 1 L �k �� Date PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Date: i ^t RE -ROOFS: 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 remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Secti ns 25505, 25533, and 25534. Ow r or autho *zed a t• 2 Date:�1� 2 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Nam Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 6 ITEMS OF 18 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609064.00 DATE ISSUED.......: 02/21/2012 RECEIPT #......... BS000016068 REFERENCE ID # 12020090 SITE ADDRESS .....: 20875 VALLEY GREEN DR SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER KORET FOUNDATION ADDRESS 1050 RALSTON RD CITY/STATE/ZIP BELMONT, CA 94002 RECEIVED FROM VILLAGES AT CUPERTI CONTRACTOR .......: LIC # *OWNER* COMPANY KORET FOUNDATION ADDRESS 1050 RALSTON RD CITY/STATE/ZIP ...: BELMONT, CA 94002 TELEPHONE ......... OPERATOR: patg COPY # : 1 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT __________ THIS REC _-NEW-BAL _____ - __________ 1.00 __________ 41.00 0.00 41.00 0.00 lADMIN_--- 1BAPPLOTHE HOURS-------- NO OF APPLIAN 2.00 130.00 0.00 130.00 1.00 0.00 0.00 1BCBSC VALUATION 500.00 1.00 0.50 0.00 0.00 0.50 0.00 1BSEISMICR VALUATION 500.00 1.00 44.00 0.00 44.00 0.00 1MPERMTTFE FLAT RATE 1.00 44.00 44.00 00 1TRAVDOC FLAT RATE ---- _---260,50 ----_-0- 260.50 0.00 0.00 TOTAL PERMIT VOICE ID DESCRIPTION VOICE ID DESCRIPTION a _ _-------- ---------------------- -- --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 #243 DATE: 02/21/2012 REVIEWED BY: bob s. APN: BP#: `'VALCJATION: $500 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair Building is PENTAMATION PRIMARY Multi -Family Dwelling >3 Stories 0 Yes eNo PERMIT TYPE: tJ'F WORK washer d er hook -u SCOPE APPLIANCE / EQUIP TYPEFEE ID QTY UNITS BP FEES Other Appliance/Equip 1BAPPt_OT 2 # $130 $130.00 TOTALS: 1\�tech. Plant C'heckT0.01 hrs $0.00 1 RMAP1 I\,tech. Permit Fee: Ih1PBRMIT Other Mech. Insp. 0.0 hrs $44.00 NOTE: This estimate does not include fees due to other Departments (Le. Planning, r Pam aWorks, P ks, Fire, a Sanitary Contact the Der Dor riot, School in o N District, etc.). These ees are based on the trelitviina in ormation available an MtSC ITEMS �_ TY/FEE FEE ITEMS f�'� E��- s��,����r�4c>.�X11; FEE Q PME Plan Check: �:�$0_00 PME Unit Fee: $130.00 PME Permit Fee: $44.00 Administrative Fee: 1A M11v $41.00 Work Without Permit? 0 Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $ 44.00 Select an Administrative Item �4 i 11 1 BSELS'MICR $0.50 3' . __S' rBcllsc $1.00 TOTAL FEE: =$260.50 SUBTOTALS: $260.50 $0.00 Revised: 1/1912012 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building5CupertinoQ` 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 OWNER ADDRESS OWNER NAME 1)12 DESCRIPTION OF WORK: We are providing you with an Owner -Builder Acknowledgment en t th d permit issued ination fyour oname as the Owner-Builden Form to make you awarer. We your responsibilities and possible risk you may inc y 9 will not issue a building permit until you have read, initialed An agent otlthe owaergannot exec to thsnnotge ua,les s returned this form to us at our official address indicated. 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 1.1 understand a frequent practice of unlicensed persons is to ei thv his or her oproperty owner tain ain laboran "Oand material Buwner- ilder" building permit that erroneously implies that the property providing 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 U 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. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license Z-4. numbers on permits and contracts. j�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. /6. I understand if I am considered an "employer" orkers' compensationdis disability insuranceea dtcontribute tothe state nd federal government, withhold payroll taxes, provide unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. er uilds YV 7. I understand under California Contracto�State intent to offer themOLicense Law, an for saeuiudnle shalbwork is performedly by residential structures cannot legally build them with the 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. I 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. OwnerBuilderFor„7_2010.doc revised 04/14110 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal 5evenue Service, the United States Small Business Admini t stand the Ca may iforn ct tia he Capartl forniaent fContrac Contractors' State el and the California Division of Industrial Accidents. I also and License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. �1 0. 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. bide 11. I agree that, as the party legally and financially respnsible or this well proposed construction activity, I will a by all applicable laws and requirements that govern owner -Builders r changes to any of the /0 12. I agree to notify the issuer of this form immediately °Sae egany dullated by laws des gned o protect the public. If tions, de information I have provided on this form. Licensed contrate be unable to you contract with someone who does riot have sustainlasnractors' Sta aeresu t of atcomplaint. Your only er emedY against unlicensed assist you with any financial loss you may tor or Contractors may be in civil court. It is also while working on youryou to nt for property,propertyhyou may be held unlicensed liable damages. If employee of that individual or firm is incuryou will be responsible for verifying whether or not you obtain a permit as Owner -Builder and wish to hire Contractors, y ensation insurance coverage. those Contractors are properly licensed and the status of their workers' comp CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) r which this permit is issued hereby affirm that there is a construction lending agency for the performance of the work fo (Sec 3097 Civ.) Lender Address: Lender Name: leted and signed by the property owner and Before a building permit can be issued, this form must be comp of the property owner's driver's license, returned to the agency responsible for issuing the permit. Note: A copy notarization, or other verification acceptable to the city may b required to be presented when the permit is issued form to veritythe ro ert owner's signature , Date: Property Owner's Signature: ,111! 55- thorization Form is required to be completed by the property owner only when designating an (NOTE: The following Au 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 the execution of which I understand is my personal responsibility, I hereby Owner, to obtain an Excluding the Notice to Property I for, sign, and file the documents necessary authorize the following person(s) to act as my agent(s) to appy 9 Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Tel No Name of Authorized Agent: Address of Authorized Agent: he under penalty of perjury that I am the property owner for the downer's dridress dver''s license,above and ) formonotarization, ored out other I declare P of theproperty above information and certify its accuracy. Note: A copy ification acceptable to the city may be required to be presented when the permit is issued to verify the property owners ver signature. Date: Property Owner's Signature: OwnerBuilderFoa-m_2010.doc revised 04/14110 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISIO 10300 TORRE AVENUE - CUPERTINO, CA 95014-3256 C U p ERT 1 N 0 (408) 777-3228 - FAX (408) 777-3333 - building cupertino,org El NEW coNsmucnoN 0 ADDITION El ALTF-pATioN/Ti ❑ REVISION / DEFERVE PROJECT PDRESP 3,2,b PHONE OW11-TERNA1111- I � -1-or) —2 -tv STREET ADDRESS r CITY, STATE, ZIP 'e 4� CONTACT NAME PHONE -v CITY, STATE, ZIP p-p(MNAL PERMIT E-MAIL FAX -I),- E-MAIL FAX EXISTIN . G . USE PROPOSED CONSTR. TYPE 9STORIES .Bjdg1pp_,2011.doc revised 03116111 STREET ADDRESS ❑ ❑ CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT [] ENGINEER El DEVELOPER ❑ TENANT &0= ❑ OWNEK-BUMDER OWNER AGEN77 BUS, tic A - LICENSE Tye LICENSE -MCENSE TYPE LICENSE NUIVIBER CONTRACTORNAIAE- . -> (�-t -i FAX E MAIL -MAIL COMP ANY NAME ,l 4± r/-00 -------------- CITY. STATE, ZIP CITY S;� STREET ADDRESS rA PHONE PHONE ':� fil) 3 tr/ln "I 00 trul" ARCl=CT/ENGR-MERNANfE LICENSE NUMBER BUS. LIC FAX E-MAIL' CON2ANYNAla PHONE CITY, STATE, ZIP STREET ADDRESS DESCRIPTION OF WORK EXISTIN . G . USE PROPOSED CONSTR. TYPE 9STORIES .Bjdg1pp_,2011.doc revised 03116111