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09030151 CITY OF CUPERTINO BUILDING DIVISION PERMITCIT �R I�QRMTI3N. BUILDING ADDRESS: PERMIT NO. 20990 VALLEY GREEN DR #623 TBD - TO BE DETERMINRn 09010151 OWNER'S NAME: PERMIT ISSUE DATE xnRFT ..TONE: S R .2009 CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH o p LICENSED CONTRACTOR'S DECLARATION m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description with Section 7000)of Division 3 of the Business and Professions Code,and my license is =y in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES Dig? License Class Lic.8 y-a DateContractor E/M/P' ti-SEE PERMIT #09030198 FOR PLAN CK ARCHITECTS DECLARATION o. U 1 understand my plans shall be used as public records C OMMEN I S. 4 O y Licensed Professional n n OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the in o following reason.(Section 7031.5,Business and Professions Code:Any city or county K m Pi which requires a permit to construct,alter,improve,demolish,or repair any structure u Z prior to is issuance,also requires the applicant for such permit to file a signed statement =G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation Y t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of $100 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type net more than five hundred dollars(M). 32609053 . 623 [11,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 Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of 9 P property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If. however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sa 1,as owner of the property,am exclusively contracting with licensed rnnlractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves themon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sec B&P C for th' rcawn Owner 1../r �ll�n�---��Bate 5 61N. '" 'WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3701 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 required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(S 100) or less) I certify that in the performance of the work for which chis permit is issued,1 shall not employ any person in any manner so as in hect" ub t rkcrs'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. Z► CONSTRUCTION LENDING AGENCY ,r 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.C.) aQ Lender's Name r1 z Lender's Address U C) I certify that 1 have read this application and state that the above information is LL 0-4 correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building construction.and hereby authorise representatives of this city to enter upon the W above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against c/i liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULA ONS. yl/ ' r S b �� Re-roofs Signature of ApplicanUContractor Date � HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Munici al Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. C]Yes o Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new mi terials for inspection. District? ❑Yes [INd 1 have read the hazardous materials requirements underChaptcr 6.95 of thc Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant.that it is my responsibility to notify the occupant of the requi me its which must be mqt prior to issuance of a Certificate of Occupancy c Signature(if Applicant Date All roof coverings to be Class'"or better Owner or authariscd agent ens arcc CITY OF CUPERTINO BUILDING DIVISION PERMIT= BUILDING ADDRESS: PERMIT NO. 20990 VALLEY GREEN DR #623 - 0 BE DEERM OWNER'S NAME: ��—� PIIthffl'ISSUE DATE PHONE: S RY CONTROL NO. ARCHrrECT1FNGINEER: BUILDING PERMIT INFO ELECT 0 PD 0 O p LICENSED CONTRACTOR'S DECLARATION Job Description 6 I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of the Business and Professions Code,and my license is no`y in fun force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES License Class Lic.B �F p Date Contract r E/M/Pn S-SEE PERMIT #09030198 FOR PLAN CK ARCHITECI's DECLARATION I understand my plans shall be used as public records COMMENTS. )dU 'U.y Licensed Professional :y OWNER-BUILDER DECLARATION 3< I hereby affirm that 1 am exempt from the Contractors License Law for the . .20 following reason.(Section 70315•Business and Professions Code:Any city or county %m 9 which requires a permit to construct.alter•improve,demolish,or repair any structure 3;w prier to its issuance,also requires the applicant for such permit to file a signed statement s G that he is licensed pursuant to the provisions of the Contractor's Liccnsa Law(Chapter 9 Sq.Ft.Floor Area Valuation aH$ (commencing with Section 7000)of Division 3 of On Business and Prof:ssions Cade)or 10 0 .. that he is exempt therefrom and the basis for the alleged exemption Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not mere than five hundred dollars(5500). 32609053 . 623 ❑I,as owner of the property,or my employees with wages as thea sole compensation, will do the work,and the structure is not intended or offered for sale(Sec,7044.Business and Professions Code:The Contractor's License Law don not apply to an owner of Required Inspections property who builds or improves thereon,and who does such workhimaelf orthrough his own employees,provided that such improvements arc not intended oroQered for sale.If. Iowa=,the-building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sok . I,az owner of the property,am exclusively contracting with licensed cantractars to concoct the project(Sec.7044,Business and Professions Cade)The Contractor's Li. cense Law does not apply to an owner of property who builds or improvat theman,and. who contracts for such pmjects with a conuactor(s)licensed pursuant to the Contractoes O License Law. ❑I am exempt under Sec B tit P C for th• reason Owner W Ka 5 b b 'WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of pepury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compan- sation,az 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..a mquimd by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued My Worker's Compensation Insurance carrier and Policy number am: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foram:hundred dollars(5100) or less) I certify that in the performance of the work for whit this , it is ismed.I shall not employ any person in any manner so as o m sob t rkcrs'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. z O CONSIRyCrION LENDING AGENCY [~i i— I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is iec.simed(S 3097,Civ.C) W Q Lender's Name — Lender's Address U 0 1 certify that I have read this application and state that the above information is lir H correct.I agree to comply with all city and county ordinances and stale laws relating to 0 V building construction,and hereby authorim representatives of this city to enter upon the W above-mentioned property for inspection purposes C4 (We)agree to save,indemnify and keep harmless the City of Cupertino against .4 y liabilities,judgmcnts,casts and expenses which may in anyway accrue against said City U Z in consequence of the granting of this permit. �(j �. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULA ONS. ( -- Re-roofs Signature of AppiieanUCantracor -" Date HAZARDOUS MATERIALS DISCLOSURE, Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupenino Munich al Code,Chapter 9.12,and the Health and Safety :retic,s«ties 25532(a)? C3 Yes All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove emh hazardous air contaminants as defined by the Bay Arun Air Quality Management all new materials for inspection. District? ❑Yes �pld 1 have read the hvanlous materials requircmenu umderChapter 6.95 of de Califor- nia Health&SafctyCode,Sections 25505,25533 and2SS4.I umicnsund thatif the building does not currently have a tenant that it is my responsibility to notify the occupant of the rcqu' mnc�nts which menu he mq�prior to issuance ora eerdrtcam of Occupancy Signature of Applicant Date -Y�6 t �'e",, -C 4 /�^'^""� 516161_ All roof coverings to be Class" "or better Owner or authorized agent ate CT OF. CITY OF CUPERTINO CUPERTINO GENERAL:BUILDING PERMIT APPLICATION FORM APN# _ Date: Building Address: Za p u ✓ee� �� 4623 Mailing Address (if different from building addr ss): Owner's.N e: 1 yq {y Phone#: ��'i ��JW`a 6f.1►i CCK j�� p HOA: (Exterior work only) Yes ❑ No -7 a ZD© If yes, provide letter from HOA Contractor: Phone: T6 Contractor License#: Fax: Cupertino Business License#: Contact: `G�. t�e f fi�c�ue✓ Phone: ��S -�25Z—? q3 Fax: Ljc Residential. Commercial Job Description: Building Permit Info: Bldg Er Elect Plumb Mech Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V [2/ /4 - 2- Valuation: 4 - 2- Valuation: / 00' Square Footage: Project Size: Express ❑J Standard [ Large❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist 7attach to the application`or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.buildit reen.or Revised 02/05/09 CITY OF CUPERTINO CU CITY OF O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sD B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly-stand alone 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B n 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B I(?(� 1" lPt�' 5 of 5 OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family(parent,spouse or child) will perform A. _ All the work authorized by this permit B. _ A portion of the work C None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to 1... _._[..--A qul-D, cv a PJ flog QLAI $:Ji a bo S Wckamu D Tose CPr 11 Q o�w us3 385 P • Iv 6Sa •63U o64 c2 b6 2 •how► l�av+ct�Co 3. -kZ I willutilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City Phone Number Type of work to be erformed 326 'ft d. 83l — 53 q- b Z&0 {cA ►` lkaktowv(Ile CA o b on L'l- S I — 2 06 - 8 a-o`i PI t SaM 3os e Cl t ..................................................................................................................................................................................... I declare-ander per�ty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information(reverse side). Property Owner's Signature: Date: G b,/b Job Address: Q09 U E �2Q,l,�I10 Permit# ©q 3 0 1 5 Any changes to the.information provided on this form shall be submitted to the City of Cupertino Build Department. a City of Cupertino Building Department pCITY OF }� (� 10300 Torre Avenue CUf E k I I�I\.J Phone: (408)777-3228 Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner-builder you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself,you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply- If you plan to do your own work,with the exception of various trades that you plan to subcontract,you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family,and the work (including materials and other costs) is$200 or more for the entire project,and such persons are not licensed as contractors or subcontractors,then you may be an employer. If you are an employer,you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding,federal social security taxes,workers'compensation insurance,disability insurance costs,and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers' compensation insurance. For more specific information about your obligations under federal law,contact the Internal Revenue Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your obligations under state law,contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale,property owners who are not licensed contractors are allowed to perform their work personally or through their own employees,without a licensed contractor or subcontractor,only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder building permit,erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors'State License Board in your community or at 1020 N Street,Sacramento,California 95814. Please complete and return the enclosed owner-builder verification form so that we can confirm that you are aware of these matters. The building permit willnot be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino Printed on Recycled Paper