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09070004hoc W U UL n< -:" am Z ±ttF� X96 �pC Z3 yZ> QFC CITY OF CUPERTINO DIVISIONPERMITL�Q: �rr `{•� T BUILDING BUILDING ADDRESS: PERMIT NO. 20875 VALLEY GREEN DR APT 31 KORET FQUNDATTOTq OWNER'S NAME: PERMIT ISSUE DATE —l��29990 SdALLEY GREEN BR #608 SE: AINCONTROL NO. ARCHTTECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing 3ofdteSttsinessand Professions Code, and mylicense is t. infullforceadeffecDivision INSTL VtASHR/DRYR UNITS INSIDE COMM' L APT BLDGS License Class Lic. # DateContractor AHI7HC -S DECLARATION RC I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance• also requires the applicant for such permit to file a signed statement License Law 9 Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's (Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code) or $100 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). 3 2 6 0 9 O E 4 .31 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, ns Required Inspections P witl 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 q 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 sale.). UrI. 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. cense 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 License Law. ❑ 1 am exempt under Spec. B & P C for this reason Q Owner Y Y I e t`� � Y A .�11nt _ Date % I WtM KER'S COMPENSATION DECLARATION 1 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 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: Carrier. 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 cenify that in the performance of the won for which this permit is issued, I shall not employ any person in any man c bject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO AMCANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. ' CONSTRUCTION LENDING AGENCY 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.) Lender's Name Lender's Address I certify that 1 have read this application and state that the above information is ' correct 1 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 I liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. " APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date / SOURCE REGU ATIONS 'I/VI J P "' � I 1 j aa -,3 .tel 7 1 Re -roofs Type of Roof Sigifaturc of Applicant/Contractor I Date HAZARDOUS MATERIALS DISCLOSURE 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 Code, Section 25532(a)?� All roofs ;;hall be inspected prior to any roofing material being installed. ❑Yes ®No If a roof i:; installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which a hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. ,'strict? ❑ Yrs MIN. 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505, 25533 and 25534.1 undcrstsnd that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements hi;h must x met p to issuance of a Certificate o� �rpar< Signature of Applicant Date � �' , All roof coverings to be Class' " or better Owner or authorized agent oto CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Bl.c: Lot: APN ......... 32509064.31 DATE ISSUED.......: 07/01/2009 RECEIPT #.........: BS)00008093 REFERENCE ID # ...: 09)70004 SITE ADDRESS .....: 20375 VALLEY GREEN DR APT 31 SUBDIVISION ...... CITY .............. CU?ERTINO IMPACT AREA ...... OWNER ............: KO:ZET FOUNDATION ADDRESS ..........: 20390 VALLEY GREEN DR #600 CITY/STATE/ZIP ...: CU?ERTINO, CA 95014 RECEIVED FROM ....: KO:ZET FOUNDATION CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: KO:ZET FOUNDATION ADDRESS ..........: 20)90 VALLEY GREEN DR #600 CITY/STATE/ZIP ...: CU?ERTINO, CA 95014 TELEPHONE ........ FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 100.00 -------------------- 1.00 0.00 ---------- 1.00 ---------- 0.00 1BREMRECEP NO. OUTLETS 1.00 42.00 0.00 42.00 0.00 1BSEISMICR VALUATION 100.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1MPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PREPPIPE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 0.00 TOTAL PERMIT ---------- ---------- 253.50 0.00 ---------- 253.50 ---------- 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- CASH --------------- 253.50 -------------------- TOTAL RECEIPT --------------- 253.50 coo 4 CITY OF CUPERTINO CITY Of CUPEkTINO GENERAL, BUILDING PERMIT APPLICATION FORM APN # _-3Date: ZC- o Building Address: j �_ l d u!/ J�2,� ✓� -S) b uildin naddress): Mailing Address (if different fM--- Ap Owner's Nar--- Koh rc+ Phone #: HOA: (Exterior work only) Yes U No 19 (4 o 9' 0 Zoc:> I If yes, provide letter from HOA Contractor: Phone: Fax: Contractor License #: 6 Cupertino Business License #: Contact: Phone: 908-- 2�6276g3 Fax: L{ def- r'l? 3- j02 --Sr Residential Commercial ❑ Job Description: , 9,,, - U Building Permit Info: — / Bldg M' Elect LTJ F lumb M" Mech 12 Type of Construction (Usage Class): Occupancy Type: 1-A, I -B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B A–Z Valuation: 100 Square Footage: Project Size: Express ❑ Standard 1Q"" Large [] Major ❑ Green Building: Please complete relevant portion o f the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. oints Achieved: For help, contact Build it Green at www.builditgrecE.or Revised 02/05/09 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, :omplete 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 32(o v� 31- 53`l 'gas) funita�' 1� ee C_ k 3o:sc C ani Hla � vux oL v" Ch ,- kvi FM kA ,isc TO -q, -A 3. Y I will utilize 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' corlpensation must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City Phone Number Type of work to be performed V 32(o v� 31- 53`l 'gas) funita�' 1� ee C_ k IVIVIAld W ani Hla oL v" Ch I declare under penalty 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:�� Job Address: °� ©� 1fA Lle '? j_k d r , 31 �t1hv-&r Permit # 6UII� Any changes to the. information provided on this form shall be submitted to the gill of Cupertino Build Department. CITY OF `;UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: 2-08? 5 V a��-v G r2�c�U 2 3 r PERMIT # 0 fO`�&17� OWNER'S NAME:C O rzc� r : CJw,0kA-T-0CJ PHONE # q00 - 25 - a 2-00 GENERAL CONTRACTOR: T?, D FAX # I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date 10 Owner/ Contractor Signature Date SUBCONTRACTOR BUSI14ESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical 1Yt uL�2o rva - oiw 5 2 -6 0 Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing LO 000 /►i 0,j T Roofing Septic Tank Sheet Metal Sheet Rock D E—u e (a 6 CO&).5 2-,L( U Tile 10 Owner/ Contractor Signature Date