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09070102CITY OF CUPERTINO PERMIT � I�f► ? I � TI 3 * BUILDINr, DIVISION BUILDING ADDRESS: PERMIT NO. 20875 VALLEY GREEN DR 38 KORET FOUNDATION nqn7oin2 nW NER'S NAME: PERMIT ISSUE DATE TZ(lRF-�T��1ID�'I eV PHONE: S CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job DCSCTTptIOn I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. INSTALL WASHER/DRYER UNITS INSIDE COMMERCIAL Ucensc Class Lic. K DateContractor BU I LD I E G ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I 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 3q. Ft. Floor Area Valuation prior to its issuance, also requires the applicant for such permit to file a signed statement License Law 9 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 eve hundred dollars (M). 32609064.38 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections q p will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of 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 - builder will have the burden of proving that he did not build or improve for purpose of le sery I, as Darter of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractors U. cense Caw does not apply to an owner of property who builds or improves themmn, and • who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. ❑ I am exempt under Sec. B tit P'7C for this ,w �%V_ 1.�/�•Q— ✓Lti =r. Date Il;/ t ~ WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 hsve 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 Workers Compensation Insurance carrier and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need trot be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the, work for yhhch this permit is issued, l shall not employ any person in any man and tsttbi 2 the Workers' Compensation `� Laws o[ Calif hs Date _+-p / Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers 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 a(rirm that them is a construction lending agency for the performance of y the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name Genders Address 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 convection, and hereby authorize representatives of this city to enter upon the for inspection above-mentioned property purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against " 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 A NON POINT Issued by: Date SO RCE REGULA ONS. 7 0 1 0 Re -roofs Signature of ApplianWCoutracmr Ditc HAZARDOUS MATERIALS DISCLOSURE Type of R, )of 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(x)? All roofs , hall be inspected prior to any roofing material being installed. ❑ Yes Plko 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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? �Iu ❑Yes 1 have mad the hazardous materials requirements under Chapter 6.95 of the 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 M the yuircmcnts which must be r7t prior to' uancc of a Certificate of —pan . Signature A Applicant Date ` l0 All roof coverings to be Class '%¢`` or better Owner or authorized agent lbatc 8 ITEMS OF 16 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: B1}:. Lot: APN ......... 32609064.38 DATE ISSUED.......: 07/10/2009 RECEIPT #.........: BS000008172 REFERENCE ID # ...: 09070102 SITE ADDRESS .....: 20475 VALLEY GREEN DR 38 SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER KORET FOUNDATION ADDRESS ..........: 20475 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: KAVITHA PENDYALA CONTRACTOR .......: LIC # *OWNER* COMPANY KOP ET FOUNDATION ADDRESS 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 TELEPHONE ......... OPERATOR: SylviaM COPY # : 1 FEE ID UNIT QUANTITY INOUNT 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 1BSEISMICO VALUATION 100.00 0.63 0.00 0.63 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 ----------- 253.63 ---------- 0.00 253.63 0.00 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 L_ _.._ro_ ed U ?):�i- uo� QI %M au f.0 s ►�_�� . Scivi 3ca CA N4UMU3 MSV__j c us�� t-e_w Pd f4j so 6 5 06� I S O G 4' She 2 S Sc-LvGllQ,tn; ifi�o Uig X76 v cy CPQ 3. _\�/ 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' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be erformed U ?):�i- W P -C G S , - 0— 90I - 9-0 6 - �K, CA s '-fo, 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: � oq-js u 1 -� v`o /� Permit# 0%Q70/0 G r--T- ��u,4 Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. i. at CITY OF CUPEkTINO CITY OF CUPERTINO GENERAL, BUILDING PERMIT APPLICATION FORM D �0 2010 z APN # -�2�3�% Date: Building Address: /r 8 d u I f JC cvt � Mailing Address (if different fro buildind address): Owner's Nam— - Koi;re4- Phone #: HOA: (Exterior work only) Yes U No ['% If yes, provide letter from HOA Contractor: (� lc)�l./L ��. Phone: LJ Fax: Contractor License #: �I Cupertino Business License #: Contact: Phone: Lq e8'_ 2-572--76q-3 Fax: dS e(-? 3- I0ZS- Residential Commercial El Job Description: , I ut 5cd-e U Building Permit Info: Bldg N( Elect Plumb Mech 12/ Type of Construction (Usage Class): Occupancy Type: 1-A 1-B 0 II/III/V-A II/III B, IV -HT, V -E A—Z Valuation: loo Square Footage: Project Size: Express ❑ Standard [N�" Large [] Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at www.buildit reg.n.or Revised 02/05/09 aFN CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPERTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1 STUCOAP Stucco AI)plications (up to 400 sf) additiona stucco application B 1 WINREP Replacement windows/sliding glass door (ea 9 windows) B 1 WINMEWSTR New Window -structural shear wall/masonry (includes plan ck fee) B 1 EPERMITFEE 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 when not over counter) Standard Plan Check (when no E/M/P) hourly -stand alone B j 1 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Seismic I:esidential B r 1 BSEISMICO Seismic Commercial B 1 TRAVDOC Travel & Documentation B 1BUSLIC Business License B ✓96,M �2 &-Ct,�> 5 of 5 1©%L&,7 P l �L%