12040113CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRACTOR: KORET FOUNDATION PF.RNIIT NO: 12040113
OWNER'S NAME: KORET FOUNDATION 1050 RALSTON RD DATE ISSUED: 04/19/2012
OWNER'S PHONE: 4082530200 BELMONT, CA 94002-2243 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. q
M ECH r RESIDENTIAL COMMERCIAL
Contractor Dale
1 hereby affirm Ihat 1 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.
1 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 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
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 regulations per the Cupertino Municipal Code, Section
9.18.
Dale
OWNER-RUILDF.R DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
I, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 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
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, for 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 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 properly 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 inconsequence 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
9.18-
JOB DESCRIPTION: APT 234 - INSTALL NEW WASHER/DRYER HOOKUP
Sq. Ft Floor Area: I Valuation: $500
APN Number: 32609041.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b Date: y -/AF— 1
RF. -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Dale:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25,%5,25533, and 25534.
Owugr�or authorized age�i1:
c ) -.r� !//�u.Date: `%— /� —/ l
�r <
CONSTRUCTION LENDING. AGENCV
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-33333 • buildinarcuoarino.oro
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS / L` .��,
APN 3 G OVi
aPk `OGl
OWNER NAMEf E r F til . / OWNER ADS RE$� Jr „ .1 ;.i/ �l
N (/ twZgL
DESCRIPTION OF WORK: 2 J, i- -
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.
Please read and initial each statement below to signify you understand or verify this information.)
. 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.
5j% 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.
5 bl 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that 1 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.
Z4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
LL 5. I 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 (3500), including labor and materials, I may be
considered an "employer' under state and federal law.
1/6. 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.
J17. 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.
3-1-1-8. 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.
0ivnerBzd1de Fom7 2010.doc revised04/14/10
5�I 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 %"%w.cslb.ca.gov for more information about licensed
contractors.
5L410. 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.
3 IL-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.
S I,/ 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 riot 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 propertyowner 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 verifv the orooerty owner's signature. /
I Property Owner's Signature:7h� (y�(2G/ti� Date:;Z-/`/ /c\
NOTE: The followin Authorization Form is required e--�---completed-- b th property - - n designating -
--- - - -
( g to 6e 6y the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
I
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 persons) 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 owners 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.
Property Owner's Signature: Date:
N,nerBfdlderFOrnl 2010.doc revised 04114/10
CITY OF CUPERTINO
62TEMS OF 12 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32609041.00
DATE ISSUED........: 04/19/2012
RECEIPT #.........: BS000016584
REFERENCE ID # ...: 12040113
SITE ADDRESS .....: 20975 VALLEY GREEN DR
SUBDIVISION ........
CITY ..............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
508 FINAL MECHANICAL
OWNER ............:
KORET FOUNDATION
ADDRESS ..........:
1050 RALSTON
RD
CITY/STATE/ZIP ..
BELMONT,
CA
94002-2243
RECEIVED FROM ....:
VILLAGES
AT CUPERTI
CONTRACTOR .......:
LIC #
*OWNER*
COMPANY ..........:
KORET FOUNDATION
ADDRESS ..........:
1050 RALSTON
RD
CITY/STATE/ZIP ...:
BELMONT,
CA
94002-2243
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
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
► 2,-),-)q Ji 13
L2CONSTRUCTION PERMIT APPLICATION Moak
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPhR 0 (408) 777-3228 • FAX (408) 777-3333 • buildina(a)cuoertino.crg
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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 behalf. I have ad 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 co cdon- I auth ' e representatives of Cupertino to enter the above -identified property for inspection purposes.
Signarureof Applicant/Agcnt
Date:-
"SUPPLEI�fENTAL L�iFORtiL4TION RE -
'
New SFD or Multifamily dwellings: Apply for demolition permit forOYERLIM
existing building(s) Demolition permit is required prior to issuance of buildingr
oc�- r-
�x>=4q' .
permit for new building.
r. �.�i�
r�" rlLs �,5•-F. j
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
P
To-=- if any Hazardous Materials zre being used as part of this project.
Copy
O:'PST.LhDARDI• ,�+•-
REF,-'
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of Planning Approval Letter or Meeting with Planning prior to
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submittal of Building Permit application.
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Bldg4pp_101 Ldoc revised 03/16/11