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12040139
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20990 VALLEY GREEN DR CONTRACTOR:KORET FOUNDATION PERMIT NO: 12040139 OWNER'S NAME: KORET FOUNDATION 1050 RALSTON RD DATE ISSUED:04252012 OWNER'S PHONE: 4082530200 BELMONT,CA 94002-2243 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lia q MECH r RESIDENTIAL COMMERCIAL Contractor Date - I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APT 623.EXISTING R-2 COMPLEX WASHER/DRYER (commencing with Section 7000)of Division 3 of the Business&Professions HOOK-UP Code and that my license is in full force and effect. 1 hereby affirm under penally 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 Sq.FI Floor Area: Valuation:$500 Section 3700 of the Labor Code,for the performance of die work forwhich this permit is issued. APN Number:32609053.00 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 to building construction,and hereby authorize rapresentutives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. 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. ;:_7 :�',- 2-,C./ Issued by: - Date Signature Dale ❑ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the properly,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for safe(Sec.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1 hereby affirm under penally of perjury one of the fallowing three declarations: HAZARDOUS MATERIALS DISCLOSURE. I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should 1 store or handle hazardous material. Section 3700 of the Labor Code;for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of Cali fomia, If,after making this certificate of exemption,I Owtw or author' ed ag 2, become subject to the Worker's Compensation provisions of the Labor Code,I must Date:��' forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and stale that the above information is for which this permit is issued(Sec.3097,Civ C.) cored. I agree to comply with all city and county ordinances and stale laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned properly for inspection purposes.(We)agree to save Lender's Address 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 of this permit.Additionally,the applicant understands and will comply with all non-point source regulations p/euperlino Municipal Code,Section 1 understand my plans shall be used u public records. 9.18. Licensed Professional 2 Signalur Date 1V 2 CITY OF CUPERTINO 6 ITEMS OF 18 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32609053 .00 DATE ISSUED. . . . . . . : 04/25/2012 RECEIPT #. . . . . . . . . : BS000016623 REFERENCE ID # . . . : 12040139 SITE ADDRESS . . . . . : 20990 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 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 ---------- ------------- --------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 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 781.50 #2756 --------------- TOTAL RECEIPT 781. 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 I OWNER-BUILDER D!SCLOSURE FORM '� C0141diUl�'ITY D.N=LO?I✓i�hiT DE?.ART64_=NT • EUILDINIS D;VISION 10300 TORREAVHNIJE • CUPERTINO. CA.950 i=.-32» CUPERTINO (=03)777-3223• =?X(403)777-3333 • `._iL^'in�Ge_s_'��_�-c Dear Property Odrner(s): An application for a building permit has been submitted in yodr name fisiing yourself as the builder cf the cropery improvements sped ied at: SITEADDRESS /7 AP14 Ep- Iv1 OWNER NAME -06'VA�lb� OWN RAD�D�S//g//!� �F�� L1�� C' DESCRIPTION OF WORK: ((� r� 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.) e5 6/ 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. S il' 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. �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. 5 f 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. V 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 ($500), including labor and materials, I may be considered an"employer' under state and federal law. 5L6. I understand if I am considered an"employer"under state and federal law, l 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. 57. 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 oder them for sale, unless all work is performed by licensed suocontractors 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. 0u'nerBuilderForm 1010.doc revised 04114110 n j CONSTRUCTION PERMIT APPLICATION r' COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 , CUPERTINO (408)777-3228 • FAX(408)777-3333•buildinD(c)cuoertino.orD ❑NEW CONSTRUCTION ❑ A/DDD.rTION ❑s ALTERATION/TI ❑ REVISION/DEFERRED ORIGINALPER=T PROIECL ADORES" ©C�/ © !/��reelzd l APN'A /r'� — ` 3�6D9 53 OWNERNAME RG I , PHONE _ E-MAB. o STREET ADDRESS CTTY STATE,ZIP FwX /er e!o 0v rfi�! o/ 9 -ion CONTACT NAME/ / PF E.MAB, r / ET 111 FAX U �� / (,Zd Y3 -/(JcZ OWNER ❑ OWNERBuoDER ❑ OWMRAGENT ❑ CONTRACTOR ❑COMRACmaAOENr ❑ ARCHITECT ❑EN44.1EE ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE EA LICENSET E BUS,LICA COMP A E-MAIL FA% STREETRE STATE,ZIP < PHONE / Lhiagahal l l - ! ARCHFCECTIENGREER NANOUCENSE NUm BUS-LIC K COMPA.NYNAME —Fm' FAX _. .. STREET ADDRESS CrrY,STATE,ffi PHONE DESCRIPTION OF WORK Gr l- ylir a FSISIn1GUSE PROPOSED USE CONSIRTYPE I ISTORffS j=-n iCi'S 25�r SFr a'SstY•i rez K--� ERrsrG NEW FLOOR DEMO TOTALg y� t;;y AREA AREA AREA NETAREA +. ;;�. � :l/ _ C- ."rte BATHROOM Rrrclmv OTHER RFMODEl AREA REMODEL AREA REMODQ.AREA t_,;eEN PORCH AREA DECK AREA TOTDECWOROi AREA GARAGE MEA:[33DETACFI i ✓•Y� - - ❑ ATTAcE _a5 ID'I/fLIQtnm4: IS SECOND Utm AYES s[com vow pT65 IMM fi�+ I 14 r aEmcwaamr No Aonmanr No iw r• - i� O P ",FSs' p r�_ ❑ ❑ I ��i PRE-r.PPLIGMON ❑ YES wmE Pao,xoECOPYOP PWT -S NAI.tE AECENRED BY''1" y, `� PAT TqL VALU 7f� d—SST Bwrnwc Mn.. p No Pl.wwvwoAPPaovACIEf1FRr3 sAX. -' ` r"rr -r" y;<:3r7•�tL..s� 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 read this application and the intorrration I have provided is correct I have read aDescription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b g constru " n. I auth representatives of Cupertino to enter the above-identifred property for inspection purposes. Signature ofApplicant/Agent �-� Date: �/ Z S1—/1 SUPPLEMENTAL INFORMATION RE UMED 'g^'T"'�"""'E'-"'�"`� Pf:1NiCfIF.CKT,1`RE'�.a'1'.�� ':xv� M 00::.�+_dq - New SFD or Multifamily dwellings: Apply for demolition permit for •^+ 'a`t`e" t VER THE�OOIATER -'f ° -TNG Vg c4 existing building(s) Demolition permit is required prior to issuance of budding Ir ,t permit for new building. 'n°i Y 'gym -.1111WNGT ?❑aECPRE55 4� NMNG PI`.AM1 AEVDN -}rq _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure s-rrA mARn_•= gyp+ VSA-dPUHwQW0 form if any Hazardous Materials are being Used as part of this project _Copy of Planning Approval Letter or Meering with Planning prior to o ' 83�e'•�FyRRnrSrarLT "d submittal of Building Permit application. 3�`E vrR is> :ir�H' BldgApp_2011.doc revised 03/16/11