Loading...
12030158CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRACTOR: MORROW-MEADOWS PERMIT NO: 12030158 CORPORATION OWNER'S NAME: KORET FOUNDATION 1050 BING ST DATE ISSUED: 03/30/2012 OWNER'S PHONE: 408253-020 SAN CARLOS, CA 94070 PHONE NO: (650)634-0682 ❑ LICENSED CONTRACTOR'S DECLARATION JOBDESCRIPTION: RESIDENTIAL CONIMERCIAI. License Class LicN UNIT 306- INSTALL WASHERIDRYER HOOKUPS Contractor Date 1 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 Sq. Ft Floor Area: Valuation: $500 perl'onnance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for Che performance of the work for which this APN Number: 32609041.00 Occupancy"type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED cored. I agree to complywith all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY F OM LAST CALLED INSP CT ON. indemnify and keep harnless the City of Cupertino against liabilites,judgments, costs, and expenses which may accrue against said City in consequence of the q 7L L 3 O / 2 granting of this permit. Additionally, the applicant understands and will comply Issued by: Dat with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. RF.-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material beteg installed. Ira roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Dale: 1 hereby affirm that 1 am exemptfrom the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, as owner of the property, or my ertployces 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 IIA7,ARDOIIS NIATF.RIA1 S DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ifeafth & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with The Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safely Code, Section 25532(x) should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should 1 use equipment or devices which emir hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District l performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal .ode, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Ilealth & Safety Code, Serti 9s 25505, 25533, an 534. Section 3700 of the Labor Code, for done performance of the work for which this i zed Owner Date: -?/J- permit is issued_ or authoriagent I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person many manner so as to become subject to the Worker's Compensation laws of Cali forma. If, alter making this cenifcate of exemption, I CONSTRUCTION LENDING AGENCV become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C) Lender's Name APPLICANT CERTIFICATION Lender's Address I cenify that I have read this application and state that the above information is corecl. 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, ARCIIITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per a Cupenino Municipal Code, Section Licensed Professional 9.18. Signature Date L CITY OF CUPERTINO 6 ITEMS OF 24 PERMIT RECEIPT OPERATOR: SylviaM COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609041.00 DATE ISSUED.......: 03/30/2012 RECEIPT #.........: BS000016410 REFERENCE ID # ...: 12030158 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 CONTRACTOR .......: KATHLEEN RICHARDS LIC # 28064 COMPANY ..........: MORROW -MEADOWS CORPORATION ADDRESS ..........: 1050 BING ST CITY/STATE/ZIP ...: SAN CARLOS, CA 94070 TELEPHONE ........: (650)634-0682 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 FLATRATE1.00 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 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • 6UILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-33333 • bi;6n05_- D2iJnJ.Om 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© /� 61 APN �j�6 BPS OWNER NAMF OWNER ADORES .J K R ' U 1 N T i// C DESCRIPTION OF WORK: ," P 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.) 5-1-1. 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 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. 5 k12. I 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. 'aJL3. I 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. 5d-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. 56. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taffies, pfovide- 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—t—I 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. 5/8. 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. On'nerBuildel"Form 2010.doc revised 04/14/10 y9. 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. I 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 - 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. 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 drivers license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued PrgpertyOwner's Signature:e::: f� ZP21Vf!57 Date: ,f�3rT/d -----_-----------------------='_---------------------------------=----------------------- --- ---------------- (N(5TE: The foliowing Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to'applyfor a construction permit for the Owner -Builder). AUTHORIZATION OFAGENT TO ACT ON PROPERTY OWNER'S BEHALF Excludirig 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): - - i Project, Location or Address: i - Name of Authorized A9 ent Tel No Address'bf Authorized Agent.' , I declare under penalty of perjury that I am the propertyownerfor the address listed above and I personally filled out the above.information add 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 owners signature. ' Date: OkmerBldlderForm 2010.docreviscd04/14/10 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • EUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 717-3228 • FAX (408) 777-3333 • buildinc aecucerf7o.ora CiJp��tTlNo ❑ NEW CONSTRTICION n An=MW n e r rD A TTn- i • n ., /o2UU l S� each o o USE PROPOSED SSE CONSM TYPE YSropm tdEWFLOOR DEMO TOTALAREA OWNER NAI+C AREA PHOT, E -PAIL KITCPicTI OTHER AREA R ODEL AREA 5ARUEA REMODEL ARFAEA / < 'Q DECKAREA,.. IOTALDECIC/PORCHAREA. ,GARAGEAREA: ❑ DETACH 57Cs�—(' ADDRESS Oopen I STA'1-c,12 nN¢S F Swim sro" ❑YESHEINGAD➢E➢t ❑ No (' '95-04Y RYES.PaovmECOPYOF PG1.'IYFA'9 NAMiPPLE ❑ NO CONTAC N By my Signature below I certify PONE � E-teAn. STREET ADDRES 11 / C STATE, ZIP�j FAX % ow:TR 13owNma.B=m ❑ OWNRAGPNI' ❑ CONIRACr'OR ❑ CONTRAaORAGPNT ❑ AAQnTcCi ❑ ENCn.'F ❑ Dc"VEI.OPR ❑ TENANr CONTRACfORNAM ' .. -, LICENSE NOMBR-'tJCEWS �E --' BUS. LICA 1 • t� COMP ANY NAME E-hfAIL FAX 1, ft -A,( t.1 W: STRESr ADDRESS ^ �/ CITY ATr' ZIP /g D ! l Q p -I-C ARCBMMENGA'Fat NAME LICENSEN EJL HUs. LIC 9 COWANYNAME Ewa . FAX STREET ADDRESS CITY. STATF. ZIP ' PRONE each o o USE PROPOSED SSE CONSM TYPE YSropm tdEWFLOOR DEMO TOTALAREA AREA NETAREAM KITCPicTI OTHER AREA R ODEL AREA 5ARUEA REMODEL ARFAEA DECKAREA,.. IOTALDECIC/PORCHAREA. ,GARAGEAREA: ❑ DETACH ❑ AMI nN¢S ISASECOfO= ❑YES Swim sro" ❑YESHEINGAD➢E➢t ❑ No Aux mo Y} AnpN ❑ YP] RYES.PaovmECOPYOF PG1.'IYFA'9 NAMiPPLE ❑ NO PLA}P�v APPROYALnETRq By my Signature below I certify 6 to ftb loll e owing. I am the property owner or aurhonaed agent to act on the property owners behalf. I have application and the information I have provided is comet I have read ffie Description of Work and verify it is accurate. I agree to comply with all ai ordinances and state laws relating to b ' - g constru 'on. I sorb representatives of Cupertino to enter the above -identified property for inspecti . SignatureufApplicaut/Agent- 'C - Date: �.�'J�Q '%cZ':-. F7s,�b STJPPLEMENPALINFORMAUTONRE .- 4US�LSFD Or Multifamily dwellings Apply for demolition permit foruildm s. Demolition ermit is re uired g() p q prior to issrance of building, new building.ercial Bldgs: Provide a completed Hazardous Materials Disclosure Hazardous Materials are being ued aspart of this project.of Planning Approval Letter orMeeting with Planning prior tof Building Permit application. purposes. B1dgipp_201J.doc revised 03/16111