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12020093CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 `/ALLEY GREEN DR OWNER'S NAME: KORET FOUNDATION OWNER'S PHONE: 4082530200 ❑ LIC'ENSED 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. 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of die 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, arid 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, Section 9.13. Signature Date CONTRACTOR: KORET FOUNDATION PERMIT NO: 12020093 1050 RALSTON RD DATE ISSUED: 02/21/2012 BELMONT, CA 94002-2243 PHONE NO: BUILDING PERMIT INFO: BLDG , ELECT ' PLUMB MEC:H '' RESIDENTIAL I COMMERCIAL JOB DESCRIPTION: APT 243 - WASHER DRYER HOOK-UP Sq. Ft Floor Area: Valuation: $500 APN Number: 32609041.00 Occupancy Type: `V' OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor'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 time 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 hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Compcnsatiotm, 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, for the performance of ttie work for which this pernhit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any pet -sol' in any manner so is to become 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 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 regulati: €ms per tine Cupertino Municipal Code, Section 9.18. Date / PERMIT EXPIRES IF WORD IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Date: !� J Issued ` r 1 - 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 NIATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain cortrpliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) 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 I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sectio s 2L:51-510"751,25-533, and 25534. Ow or authorized ag j Date:__L 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 Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional, CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg 6 ITEMS OF 18 COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32609041.00 DATE ISSUED.......: 02/21/2012 RECEIPT #......... BS000016068 REFERENCE ID # 12020093 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 CUPRERTI CONTRACTOR ....... COMPANY KORET FOUNDATION ADDRESS 1050 RALSTON RD CITY/STATE/ZIP ...: BELMONT, CA 94002-2243 TELEPHONE ......... METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 781.50 --------------- 781.50 VOICE ID DESCRIPTION - 301 ROUGH PLUMBING 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL REFERENCE NUMBER ---- --------------- #2544 VOICE ID DESCRIPTION -------- ---------------------------- 303 ROUGH MECHANICAL QUANTITY AMOUNT PD -TO -DT THIS REC- NEW FEE ID UNIT ---------- -- -BAL- ----- 1ADMIN --------- HOURS ---------- 1.00 ---------- 41.00 0.00 0.00 41.00 . 13000 0.0 0.00 1BAPPLOTHE NO OF APPLIAN 2.00 130.00 1.00 0.00 1.00 O.UO 1BCBSC VALUATION 500.00 0.50 0.00 0.50 0.00 1BSEISMICR VALUATION 500.00 44.00 0.00 44.00 0.00 1MPERMITFE FLAT RATE 1.00 44.00 0.0- 1TRAVDOC FLAT RATE 1.00 ------0.00 -----44-00 --------0.00 260.50 260,50 0.00 TOTAL PERMIT METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 781.50 --------------- 781.50 VOICE ID DESCRIPTION - 301 ROUGH PLUMBING 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL REFERENCE NUMBER ---- --------------- #2544 VOICE ID DESCRIPTION -------- ---------------------------- 303 ROUGH MECHANICAL CITY OF CUPERTINO 1 vwF7nw G DIVISION FEE ESTIMATOR — BUILDIN ADDRESS: 20975 valley green #27 DATE: 02/2112012 REVIEWED BY: bobs. BP#: VALUATION: $50=0 APN: Permit PLAN CHECK TYPE: Alteration Addition Repair PERMIT TYPE: Mechanical Permit Mu mily W Ir g Buildina is PRIMARY St( (e) N o USE: Multi -Family Dwelling >3 Stories 0 Yes PERMIT TYPE• WORK I Wnchqnr (irvpr hook-up SCOPE I APPLIANCE / EQUIP TYPE FEE ID Other Appliance/Equip IBAPPLOT TOTALS: mech. Plan Check 10.0 1 hrs $0.00 BP FEES QTY UNITS 2 # 1 $130 $130-00 I RMAP1 Mech. Permit Fee: JAIAPERMIT "'fT Other Mech. Insp. 0.0 firs $44.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public �vorks, Fire, Sanitaty Sewer District, School District, etc.). Thesej�Zs tire based on the prelining ry information available and are only an estimate. Contact the Dept tor addn'l F E E ITEMS iU� L" FEE QTY/FEE MISC ITEMS PME Plan Check: I $0.00- PME Unit Fee: $130-00 PME Permit Fee: $44.00 ]ADMIN $41-00 Administrative Fee: 0 Yes 0 No $0.00 Work Without Permit? Travel Documentation Fee: i TRA VDOC $44.00 IBSEISAIICR $0.50 Select an Administrative Item po� 1.00 $ .d JBCBSC SUBTOTALS: $260.50 $0.00 TOTAL =FEE:$260.50 Revised: 1/19/2012 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION is 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • buildin gc—u- ertlno.o'� CUPERTINO Dear Property Owner(s): application for a building permit has been submitted in your name listing yourself as the builder of the property a An pp improvements specified at: aP# 7 APN r SITE ADDRESS� �� OWNER AD OWNER NAME A_/F)0 __r OF WORK: 0. m to make you aware 'n you with an Owner -Builder Acknowledgment and Information issued infyouroname as the Owner -Builder We We are providing y incur b having this p your responsibilities and possible risk you may y yunderstanding provision, signed, and will not issue a building permit until you have read, initialed our ftheowner of each is form to us at our official address indicated. An a authority. the owner cannot execute this notice unless returned this approval of the permitting ty you, the property owner, obtain the prior app OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION ou understand or verify this information.) (DIRECTIONS: Please read and initial each statement below to signify y �� persons is to have the property owner obtain an "Owner- / , - I understand a frequent practice of unlicensed p Builder building permit that erroneously implies that the property owner is providing his or her own labor and materia ies sustained I as an Owner -Builder, may be held liable and subject rrty p 10 seooe�yfinancial y. homeowner's insurrance may not personally. , an unlicensed person and his or her employees while working on cting as an Owner -Builder and am aware of the limits of my provide coverage for those injuries. I am willfully a insurance coverage for injuries to workers on my property. propert owners unless they are responsible for d to ;5J/2. I understand buildingno hiring lasare not licensed rContractorbo asgsume t s responsibility. the construction and ar that I d on the �3.1u understand as an "Owner -Builder" I am the responsible op tractory of randrhavi g thepermitfiled inchis dor her may protect myself from potential financial risk by hiring a licensed C name instead of my own. e required by law to be licensed and bonded in California and to list their license �V4. I understand Contractors ar numbers on permits and contracts. to or otherwise engage any persons, other than California licensed Contractors, and the ;44 5. 1 understand if I employ ria dollars ($500), including labor and materials, I may e total value of my construction is at least five hund considered an "employer" under state and federal under sw. tate and federal law, I must register with the state and �6. I understand if I am considered an "employer" taxes, provide workers' compensation disability insurance, and contribute o federal government, withhold payroll failure to abide by these laws may subject unemployment compensation for each "employee." I also understand my me to serious financial risk. er uilds ly understand under California Contractors' State License offer themO or sale, udnlesshalbwork is performed by residential structures cannot legally build them with the intent to licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work on is performed under contract with a licensed general building I be held liable for �8. I understand as an Owner -Builder if I sell the property for which this permit is issued, may ' ncial ersonal injuries sustained by any subsequent owners) that result from any latent construction any financial or P defects in the workmanship or materials. 011,1erBuilderForm_2010.doc revised 04/14110 �2,�,z 0013 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3258 (408) 777-3228 FAX (408) 777-3333 • buildinalacuoertino.org. c pERT1 0 ❑ NEW CONSTRUCTION E]ADDITION ❑ ALTERATION I TI ❑ REVISION / DEFERRED i ORIGIIdAL PERMIT R PROJECT ADDRES loft X .1" - .� PHO -MAIL OWYERNAME j� / � y i / STREET ADDRESS Com.G ZL . fes' /} C 1 STATE, Z 0 F 4X CONTACT NAME � „ O� (yam PHONE rt �� E-MAIL CITY, STATE, ZIP FAX STREET ADDRESS � ❑ OWNER -BUILDER ❑ OWNERAGE'NT ❑ CONTRACIOR ❑ CONTRACIORAGENT ❑- ARCHITECT ❑ EZiGINEER ❑ DEVELOPER ❑ TENANT OWNER LICENSE NUMBER LICENSE TYPE BUS. LIC # CONTRACTORNAMS- . ( � . E-MAIL FAX COMPANYNAME y Y ' � .V` L L.y .41i0 STREET ADI2RESS j I / - - - CPI STAT 1 ..01- -j !1 a- D4 �. �L PHONE �r /S-0 ) Jl LEER NAME LICENSE NUMBER BUS. L ARCHITECT/ENGIC # FAX COMP ANY NAME E-MAIL CITY, STATE, ZIP PHONE STREET ADDRESS DESCRIPTION OF WORK