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12040138CITY OF.CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRACTOR: KORET FOUNDATION PERMIT NO: 12040138 OWNER'SNAME: KORET FOUNDATION 1050 RALSTON RD DATE ISSUED: 04/25/2012 OWNER'S PHONE: 4082530200 BELMONT, CA 97002-2243 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. q r r r MECH RESIDENTIAL COMMERCIAL Contractor Dale 1 hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: APT 226- 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. 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, m provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $500 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. APN. Number: 32609041.00 Occupancy Type: APPLICANT CERTIFICATION . I certify that I have read this application and slate 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 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. Issued by Date: % 1.r/ 2 Signature Date ❑ OWNER-RIIILDER DECLARATION RE -ROOFS: All roofs shall be inspected prior to any roofing material beiig installed. If a roof is 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. 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, Signature of Applicant: Dale: Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sce.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following 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. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 1 have and will maintain Worker's Compensation Insurance, as provided for by Safety Code, Section 25532(x) should I 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 Ouality 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 California. If, after making this certificate of exemption, I O�or aulholrzed aayA: become subject to the Worker's Compensation provisions of the Labor Cade, I must Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 1 hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued (Sec. 3097, Civ C.) correct. I agree to comply with all city and county ordinances and slate laws relating Lender's Name to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property 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 granting of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION with all non -point source regulations per the Cupertino Municipal Code, Section I understand my plans shall be used as public records. 9.18. __ Signature" 1Dale—� Licensed Professional ,tti• J 6 ITEMS OF 18 CITY OF CUPERTINO. PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN 32609041.00 DATE ISSUED.......: 04/25/2012 RECEIPT #.........: BS000016623 REFERENCE ID # ...: 12040138 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 CUPERTI CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: KORET FOUNDATION ADDRESS ..........: 1050 RALSTON RD CITY/STATE/ZIP ...: BELMONT, CA 94002-2243 TELEPHONE ........: OPERATOR: patg COPY # : 1 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 5.08 FINAL MECHANICAL OWNER -BUILDER DISCLOSURE FORM, Niz COMiklUh'ITY DEVELOPMENT DEEP' ;R T MEh:7 •E�^ LD!icG DiVI_10!' 10300 TORRE,AVENUE - CUPERTINO, CA 8501 ""-.:2» CUPERTINO (403)777-3228-FA.X(40S)777-3333 Dear Property O:vner(s): An application for a building permit has been submitted in ycur name !fisting yourself as the builder or the property improvements specified at: SITE ADDRESS 1 ^ P (/ C APIJ �� aPm OWNER NAf✓�E • 6lZET d�fJIJAT/4�/ OWNER ADDRESS !/,�!� e�f a �fir;�� DESCRIPTION OF WORK: Oar �P�' ryes O 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 urrvrtrvh i wry- .. to signify you understand or verify this information.) 5 -Lt. 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. t, 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 homeowners 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_.V_2. 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. U1 3. 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. SU 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. 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. 5 t/ 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'ab_ide by these laws may subject me to serious financial risk. 5// 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 humbe(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. _ -_ _ Oir_nerBuilderForm_2010.doc revised 04/14/10 - - ccntraciers. S ( i0.1 am aA'a re of and consent to an Owner-Bulh.er )biking p=. -mit aopil�--d for lily flan -, anti uFff-B=nd Chat I am the parLy legally and financially responsible for proposed consru coon activity at file site adc'rss !istsd aborta. :511 i 1 agree that, as the party legally and financially responsible for This proposed Construction, acti��h�, I will abide by all applicable laws and requirements that govern Ovmer-Builder as vvei1 as employers. SV 12. 1 agree to notify the Issuer of this form Immediately of any additions, deletions, or cllanc;es to any of the information I have provided on this form. Licensed contractors are regulated by lavis 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 b 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 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 owner's si nature. Prgperty Owner's Signature: Date: !fZ' 1. ------`----------------------=------------------------='---------------------------------------------------------- --- -- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an 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 Excluding 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): Er9ject;Location or Address: Date: Avnel B!/ildel'Fomz 2010.doc revised 04Q4/10 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION x e 7 ii i t Abid z >- ii iy'0 u ADDRESS: 20/75 valley green #226 DATE: 04/25/2012 APN: BP#: REVIEWED BY: bobs. 'VALUATION: $500 'PERMIT TYPE: Building Permit =PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: I E!er Pe, 'mil) rc: PENTAMATION 1RMAP1 PERMIT TYPE: WORK existin R-2 com les W/D hook-up SCOPE /'!111,11). bup. f,c,: x e 7 ii i t Abid z >- ii iy'0 u Mech. Plan Check0.0 hrs $0.00 Plumb. flat (:heck h%ar. Plan. Ojv_,k Mcch. Permit Fee: IAtPERMIT I'ianrb. Avmil ('re: I E!er Pe, 'mil) rc: Other Mech. Insp. 0.0 hrs $44.00 Other I'lumb Imp, Uurrr t_'hr. Ls/:. El tl;:rh, leap, Lc,•: /'!111,11). bup. f,c,: Ucr.. hl,r. III,: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. erc). These fees are based on the areliminaryinformation available and are only an estimate. Contact the Dept for addn'I info. FEE ITEMS (1-ce Resolution 11-053 l:7 711/1 U FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 2 # $130.00 Mechanical IBAPPLOI' I Other Appliance/Equip Suppl. PC Fee: (F) Reg. OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feefl Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 Administrative Fee: 1ADMhv $41.00 Work Without Permit? Yes (F) No $0.00 Advanced Planning Fec: $0.00 Select a Non -Residential Building or Structure G A Travel Documentation Fee: ITRAVUOC $44.00 Sunny Motion Fec: IBSF.ISA1/CR $0.50 Select an Administrative Item Blde Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $130.50 $130.00 TOTALFIEE:-7 $260.50 Revised: 04/01/2012 J�u✓t ��3� CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 GUF'[ER71N0 (408) 777-3228 • FAX (408) 777-3333 • buildina(a)cuoertino.ora ❑ NEW CONSTRUCTION ❑ ADDITION n Ar TFRATTnN/TT n nnvncrnu rnnccnnrn nnrr_nr�. nz•�..,".� PROJECT ADDRES". Is- APN9 3z Wo q 111 OWNERNAh¢ - t2L'T PHONE K L�Ot/N / N O E-MAIL STREET ADDRESSe U C 1; STATE, ZIP FA% 91- CO1`TACr NAME&x/Z/�A / PHONE E-MAIL U �. - 5u i+ Wre lT� STREETADOAESS Z da/e CM. STATE, ZIP FAX Arch OWI ❑ OW -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑COMr CTORA= ❑. AROTITECT ❑ ENGN1 ❑ DEVELOPER ❑ TEYANT CONTRACTOR NAME- LICENSE MES, - LICEYSE TYPE BUS. LIC9 r— c COMPANY NAME tiC R tt)-AAV w1 E -MAB. FAX STREET ADD Z2 PHONE fATE, 9,i ,2t d. - (It g0 ARCHITECT/ENGVJ MR NAME LICENSE NUMBER BUS. LIC 9 COMPANY NAMEE MAJL . FAX SrRFET ADDRESS CITY. SrATF, ZB PHONE DESCRIPTION OF WORK PROPOSFSE CON5YE arORExt=OUSE .yOFFIC • -_Ey Wt.. 3. EXISrG AREA N FIDOR ARFA DET10 AREA TOTAL NETARFA +MZ =41�" $ �'1�j��l"P�S� BATHROOM REMODEL AREA - KRCEE N REMODEL AREA OTHER R7:1fODEL AREA �r w f PORCH AREA DECK ARFA TOTALDECK2ORCHAREA GARAGE EI DETACH ❑ATTACH lyV". �� V �jy �j IDWkL,N'O UNQSuASCCotD TINT �YFS SaCotm STORY NGAD B[DNi EINo wDD[}]tlVr NO .. '1'•' .a Yds_"}._. iu,a�ces` T,d$C• PRErVPLRa' }ION ❑ lT3 EYES, PROVp)ECVPYW ITJrNThA'S NAVE' N-ANNBIG APfl.1 �NO PLANNNDA aovALLETN �ye f�ElV(E.D Ii� f'S+� 2TQTACjW,LL»UAAD �'N"~T By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the behalf I have read this g property application and the information I have provided is correct Ihave read the Description of Work and verify it is accurate. 7 agree m comply with all applicable local agree ee to Comply ordinances and state laws relating to lding to ctiorL I a rize representatives of Cupertino to enter the above -identified for inspection purposes. . Signature of ApplicanVAgent: eprroperty Date: �%" Z d _ SUPPLEMENTAL INFORMAEON RE New SFD or Multifamily dwellings: Apply fordemolition permit for, existing buildings) Demolition is to issuance oRY permit required prior g riot ofbuildm for building. -,.;� - �'� permit new _i-ud ` z�� }qP' �rREVTPw -L v Commercial Bldgs: Provide acompleted Hazardous Materials Disclosure form if any Hazardous Materials are being used Ps part of this project Copy of Planning Approval Letter Meeting Planning b LA cE y6 Tyu�i^;'} RTREIU P \ �' _ or with prior to scbmittal of Building Permit application. z3� nLATOOR �r* :Ya`OSSENYSR�Ob"ME.VT ®..1isANccxxrssweR7DrsTiztC LL'Slm..tl.TH,..-i:! BldgApp 2011.doc revised 03/16/11