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12040137CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20875 VALLEY GREEN DR CONTRACTOR: KORET FOUNDATION PERMIT NO: 12040137 OWNER'S NAIVE: KORET FOUNDATION 1050 RALSTON RD DATE- ISSUED: 04252012 OWNER'S PHONE: 4082530200 BELMONT, CA 94002 PHONENO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r Lic. Contractor I hereby affirm that 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. I hereby affirm under penalty of perjury one of the following two declarations: 1 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 peril 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. 1 agree to comply with all city and county ordinances and stale 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 -BUILDER DECLARATION 1 hereby affirm that I 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). 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 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. 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 Califomia. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, 1 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 regulations per the Cupertino Municipal Code, Section 9.18. �. MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: APT 3 - EXISTING R-2 COMPLEX WASHER/DRYER HOOK- UP Sq. FI Floor Area: I Valuation: $500 APN Number: 32609064.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material berg 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 1 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, Sections 25505, 25533, and 25534. Own authoriz d age- / ) v' Dale•�� G 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 6 ITEMS OF 18 CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609064.00 DATE ISSUED.......: 04/25/2012 RECEIPT #.........: BS000016623 REFERENCE ,ID # ...: 12040137 SITE ADDRESS 20875 VALLEY GREEN DR SUBDIVISION ......: CITY CUPERTINO IMPACT AREA ....... OWNER KORET FOUNDATION ADDRESS 1050 RALSTON RD CITY/STATE/ZIP ...: BELMONT, CA 94002 RECEIVED FROM ....: VILLAGES AT CUPERTI CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: KORET FOUNDATION ADDRESS...........: 1050 RALSTON RD CITY/STATE/ZIP ...: BELMONT, CA 94002 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 (::Iz'-1 (---, i 3-I �� CITY OF CUPERTINO I- 1 FEE ESTIMATOR — BUILDING DIVISION &iiiADDRESS: 20875 valley green #3 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: iv(% Pep mil 1, Cc: PENTAMATION 1RMAP1 PERMIT TYPE: WORK existin R-2 com les W/D hook-up SCOPE Plumb. imp.. FrC: NOTE., This estimate does not includefees due to other Departments (i.e. Planning, Public IForks, Fire, Sanitary Sewer District, School District, eta). These fees are based on the areliminary information available and are only an estimate Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/I U Mcch. Plan Check 0.0 hrs $0.00 Phuuh. Plan Cherk l:h:c. Plan c heel. Mech. Permit Fee: lA1PF•RMIT Phunb. Noon/ Fee: iv(% Pep mil 1, Cc: Other Mech. Insp. 0.0 hrs $44.00 Orhei Phiiab lny,. Olhrr F/... hasp.El ahaeh. 6h.y;. Ir... Plumb. imp.. FrC: L'lc:. hr.<p. Vve: NOTE., This estimate does not includefees due to other Departments (i.e. Planning, Public IForks, Fire, Sanitary Sewer District, School District, eta). These fees are based on the areliminary information available and are only an estimate Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/I U FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F 2 # $130.00 Mechanical I BAPPLOT I Other Appliance/Equip Suppl. PC Fee: 0 Reg. OT FO.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fcefl Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 ("onsla-uction 1'1x% Administrative Fee: 1ADA111v $41.00 Q G Work Without Permit? Yes IE) No $0.00 Advanced Planning Fcc: $0.00 Select a Non -Residential Building or Structure E) 0 Travel Documentation Fee:ITRAVDOC $44.00 Strong Motion Fee: IBSFISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $130.50 $13 .001 TOTALTkk:,j $260.50 Revised: 04/01/2012 CUP ERTINO OWNER -BUILDER DISCLOSURE FORM C01,11:4UNITY D=VHL OPI:4__N i D= ..RTIO=N'T • R;UILD!NG Di :SIGN 10300 TORRE AVENUE • CUPERTINO. CA 95011-3255 (1103) 777-3228 • FAX (406) 777-3333 • �uG�in�_ cusa'ioo.:;r Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the properly improvements specified at: SITE ADDRESS D _Iel APN 3o2,6 D M b ` aPm OWNER NAME OWNER ADDRESS DESCRIPTION OF WORK: 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.) 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 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 J 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. S /� 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. 5_Z_4. I understand Contractors are required by to be licensed and bonded in California and to list their license numbers on permits and contracts. 3 1/5. 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. 5-16. 1 understand if I am considered an "employer" under state andfederal law. I must register with the state and federal government, withhold payroll taxes, provide workers' compensation iiisability.inaurance, and contribute to unemployment compensation for each"employee." I also understand niy failure to`abide by these laws may subject me to serious financial risk.' S V 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 su6cbhVact6rs and the nurhber 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. 5AZ8. 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. ._ _ avnerBuilderFom 2010.doc revised 04/14/10 c, ��a ir! (r jl `•J c_ 7�i J'7 -�'SI 3 (2752)0- _.i.------- !__- 5 V 1 am a':'are of end consen. io an OUvncFBL!Ilder DUild!ng Germ!t aUDIF3d fOF!n n!V nema, cn:1 Jefsiand .hat i am the parry leeally and nnanclally responsible for proposed consiruciion ac_ivity at iiia sG:e address lisied abo1!e. 5✓ 11. 1 agree the,, as the pa Ly legally and financially responsible for this crcposeci consiruCdon adt"'iry. I v. til abide by all appliraNe lauds and requirements that govern Croner-Euilders as we!I as employe;. 51,1) i2. I agrae to not y tl-e issuer of this form immediately of any additions, deietions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect :he publia Ir 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 he 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, thisform 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 signature. Prgperty Owner's Signature: Date: - V --------------------------------------------------------------------------------------------------------------------------------------------- (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 fora construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF F�ccluding.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): Project Location or Address: Date: c nerBuilderForm_2010.doc revistd 04/14110. . V j I CUPERTINO ❑ ZWCONS-auc TON CONSTRUCTION PERMIT APPL ICATION 10300 TOF, :RE .-VEI'.lj • CUT=RTi.'i0, C. _ ('.08) 777-3223 • FAX (-.Oc) 777 -33<3r -I • ccii=fnc.^a;_a: ;icac - _ 117 e r -o e 171 i, --- - r Bldg4pp_2011.doc revised 03/16111 ?Ror_cT ADcR=sr A -OR E -T Fn o, nO ti SiZ=-.:DORESS�D F.>_( ria - 0k CONTACT FWME / PHO\: - sTREET ADDRESS Cm, ATc. Zu' EA.T OWNER ❑ 0w -B[ u ❑ 0WI AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ EtiGR' ❑ DEVELOPER ❑ TENANT CONTRACTORNA.ME LICENSENUMBElt. 1 LICENSE TYPE G10 BUS. LICA COMPANY NAA¢ E -MAB. FA% STREET ADDRESS,STATE• 5 i ZIP PHONE rl ul / S -I y ARCtRTECr/EJGTNEER NAt n: LICINSE NUMBER BUS. LIC9 , COMPANYNAME E -MAD. . FAX STREET ADDRESS CRY, STATE, Z@ PHONE DESCRIPTION OF WORK r1 (2/- F]OSZDJGUSE ..... PROPDSFD USE CONSIX TYPP 0smiuFS HIG�s POS."•.= E#STO AREA NEW FLOOR DEMO TOTAL NErAREA BATHROOM KRCHEN OTBER REMODE]. AREA REMODEL AREA REMODEL _ti�4Lr POACHAREA DECK AAFA, TOTALDECR ORCHARFA GARAGEARE&EOI ACH •;51,_ � - ❑ ATLACN -i' _ - IDWD.fA'OIINPS ISASEcamur I' ❑m sCCONDSm ❑yr_5 _ 1 PAF.MPLIGSION ❑TES 6TES. PROVIDE NPYOF nwNIRR'S NAI. � 1';4i� P.: • OE[4 ftY�: A .- T41TAL Pu1NN4VO APPLI ❑ A'p PINRANOAPP0.0VA4LtTI}R ��-�} x '$r - E' J YDS _. N A ON *¢ N By my signature below, I certify to each ofthe following: I am the property owner or authorized agent to act on the property owner's behalf I have read this application and the information Ihave provided is comet I haver the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b ' g co 'art I a representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent Date: SUPPLEMENTAL INFORMATION REQ _ New SFD or Multifamily dwellings: ,Apply for demolition permit for - - •�+rr ^'; ' existing building(s). Demolition permit is required prior to issuance of building permit for new building. _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure - r• D oµ•° - a... ? -form if any Hazardous Materials are being used as part "ofthis project'- _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building permit application. r Bldg4pp_2011.doc revised 03/16111