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09060051 CITY OF CUPERTINO hg BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 20800 VALLEY GREEN DR #402 TBD — 'IO BE DETERMINED OWNER'S NAME: PERMIT ISSUE DATE 7 ; A 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 Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect INSTL IAASHER/DRYER UNITS INSIDE COMM'L APARTMENT Ci License Class Lic.M - p Date Contractor BLDG,UIQ I T 402 W ARCHITECTS DECLARATION v. U I understand my plans shall be used as public records DW p y Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the is p O following reason.(Section 7031.5,Business and Professions Code:Any city or county K,0,Pi which requires a permit to construct,alter,improve,demolish,or repair any structure y Z prior to its issuance,also requires the applicant for such permit to file a signed statement =o that he is licensed pursuant to the provisions of the Contractor's LiLense Law(Chapter 9 Sq.Ft.Floor Area Valuation yI- (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 not more than five hundred dollars(5500). p 1,as owner of the property,or my employees with wages as their sole compensation, 32609040 .4 0 2 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 does not apply to an owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements arc not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- buillAr will have the burden of proving that he did not build or improve for purpose of )• 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- ccnse Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's 4L' Law. exempt ` under Sec. ,B&PC Owner d1,C1_S Date or s/G n WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 1 have and will maintain a Certificate of Consent to self-insure far Worker's Compen- ..tion,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 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: Grier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certifv that in the performance of the work 0 which this permit is issued,I shall not employ any person in any maay&r �CEJ�st�ject o the Workers'Compensation Laws of California le o ��DJJJ M 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 Qforthwith comply with such provisions or this permit shall be deemed revoked. Z 0-4 CONSTRUCTION LENDING AGENCY [~-r I hereby affirm that there is a construction lending agency for the performance of (Y, the work for which this permit is issued(Sec.3097,Civ.C.) WR.Q Lender's Namc a z Lender's Address U I certify that I have read this application and state that the above information is (S. correct I agree to comply with all city and county ordinances and state laws relating to 0 building construction.and hereby authorize representatives of this city to enter upon the Uabove-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against ►F-t liabilities,judgments,toss 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 6 SOURCE REGU ONS. r.*_A') I (oobcq Re-roofs Signature of Applicant/Conuactor IDate HAZARDOUS MATERIALS DISCLOSURE Type of F.00f Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cole,Section 25532(a)? L IAll roofs shall be inspected prior to any roofing material being installed. ❑Yes O'Igo' 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 it hazardous air contaminants;as dcftn by the Bay Area Air Quality Management all new materials for inspection. .strict? ❑Yes 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the M utrements which must be p eL .rto issuance 0.fa Ccrdficate of P� Signature of Applicant Date =.c r���X t -�\ C� OC/ g PP rt Owner or authorized agent bate All roof coverings to be Class or better CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32609040 .402 DATE ISSUED. . . . . . . : 06/08/2009 RECEIPT #. . . . • • • • • : BS000007907 REFERENCE ID # . . . : 09060051 SITE ADDRESS . . . . . : 20800 VALLEY GREEN DR #402 SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER UBS ADDRESS . . . . . . . . . . : 20800 VALLEY GREEN DR CITY/STATE/ZIP . . . : CUFERTINO, CA 95014 RECEIVED FROM UBS CONTRACTOR TBE - TO BE DETERMINED LIC # 00096 COMPANY TBE - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- 1BCBSC VALUATION 100 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BREMRECEP NO. OUTLETS 1 . 00 40 . 79 0 . 00 40 . 79 0 .00 1BSEISMICR VALUATION 100 .00 0 . 50 0 . 00 0 . 50 0 . 00 lEPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 1MPERMITFE FLAT RATE 1 .00 40 .79 0 . 00 40 .79 0 . 00 1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 1PREPPIPE FLAT RATE 1 .00 40 .79 0 . 00 40 .79 0 . 00 1TRAVDOC FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 .00 -- ------ ---------- ---------- ---------- TOTAL PERMIT 246 .24 0 . 00 246 .24 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------- CASH 246 .24 --------------- TOTAL RECEIPT 246 .24 OWNER-BUILD R 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 we rk C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hires.to do: A. All of the work B. A portion of the work (complete section below) Contractor Address/City. —T—Phone # State License # Type of work to PO.30a(23 27(� c 4/vu-1 yS 77 " „2�1 (�5 L MC)ay aw 1/Y) b 6 C+)5 �o vrr. s r Wi n. 650 -6-5q0662 L 5 3. L� I will utilizeunlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understanc.that I may be an employer (see reverse side). A Certificate of Insurance covering workers' con ipensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City . Phone Number Type of work to be performed DoNW) m►X 2Ut3� v tI I declare under penzty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse . Property Owner's Signature: Date: Job Address: 90800 V A L LE`( 6,E C6 k, # b Ct Permit# 0600 S Any changes to the information provided on this form shall be submitted to theCity of Cupertino Build Department. CITY OF C',UPERTINO CUPEf�TINO GENERAL, BUILDING PERMIT APPLICATION FORM APN # Date: — O a� b e r _0 ctBuilding Address* Mailing Address (if different fr building address): 74� Owner's Name: S Phone#: U g - ZS� HOA: (Exterior work only) Yes U No 14o -02-c-c If yes, provide letter from HOA Contractor: Phone: Teo Fax: Contractor License#: T�6 Cupertino Business License#: Contact: Phone: yogi. -2_5-2_,76q,3 Fax: Residential Commercial Job Description: v Co w� vti e fGt �� Q.��i v►��-F f3,j dc) I P Building Permit Info: Bldg V Elect Plumb Nr' Mech to Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B [I II/III/V-A ❑ II/III B, IV-HT,V-I314- 2— Valuation: — 2— Valuation: /�O Square Footage: Project Size: Express ❑ Standard NT'� Large [] Major E] Green Building: Please complete relevant portion ,)f the Green Building/LEED Checklist & attach it to the application or if applicablc, include in plan set& the sheet index. 'oints Achieved: For help, contact Build it Green at www.builditgrf en.or Revised 02/05/09 C CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEi�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1 STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea :; windows) 1 WINMEWSTR New Win,iow-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M l 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-st;ind alone 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT C TYPES 1 BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel & Documentation B 1BUSLIC Business License B �� � P ► �� 5of5