09070101CITY OF CUPERTINO
BI ILDING DIVISION PERMIT
BUILDING ADDRESS:
20975 VALLEY GREEN DR 309 KORET F
OWNER'S NAME:
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ARCHITECI7ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70110) of Division 3 of the Business and Professions Code. and my license is
in full force and effect
License Class Lie. k
DateContractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors 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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not mors than five hundred dollars ($500).
❑ 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
and Professions Code: The Conuactoes 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 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
1, as owner of the property, am exclusively contracting with licensed contractors to
consuw the project (Sec. 7044, Business and Professions Code:) The Contractors 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 Contractors
License Law.
❑ 1 am exempt under Sec / B & P C for this n
'honer j �` ^�f G'w "� Date t�
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 for Workers compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 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 Polity number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('This section need riot be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of thq work for hich this permit is issued. 1 shall not
employ any person in any mannar� tg136% taj�to the Workers' Compensation
Laws of California. Date LL vv
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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Were is a convection lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that 1 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 in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -PO NT
SOURCE REGULATIONS.
Sign&um of ApplicamfContractor 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)?
❑ Yes 91N.
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
District?
C] Yes 0-9.—
I have read the havardcws materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 7.5534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify We occupant of the
requirements which must be met or to u of a Certificate of Oc pancy.
U
Owne" r or authorized agent Dao
Job Description
INSTALI, WASHER/DRYER UNITS INSIDE COMMERCIAL
APARTMENT BUILDING
3q. Ft. Floor Area
APN Number
32609064.309
Issued by:
Re -roofs
Type of Roof
Valuation
Type
Required Inspections
All roofs ;;hall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new m iterials for inspection.
Signature of Applicant Date
All roof coverings to be Class 'W' or better
CITY OF CUPERTINO
8 ITEMS OF 16 PERMI" RECEIPT OPERATOR: SylviaM
COPY # : 1
Sec: Twp: Rng: Sub: B11:: Lot:
APN ........: 32609064.309
DATE ISSUED.......: 07/10/2009
RECEIPT #.........: BS000008172
REFERENCE ID # ...: 09070101
SITE ADDRESS .....: 20975 VALLEY GREEN DR 309
SUBDIVISION ......
CITY .............. CUPERTINO
IMPACT AREA ......
OWNER KORET FOUNDATION
ADDRESS ..........: 201375 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: KA`IITHA PENDYALA
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: KORET FOUNDATION
ADDRESS ..........: 20!375 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, 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
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
METHOD OF PAYMENT
AMOUNT
REFERENCE
NUMBER
----------------- ---------------
CREDIT CARD
507.26
--------------------
master card
---------------
TOTAL RECEIPT
507.26
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 w ork
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
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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
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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: ��6�d 0 -
Date: �r 40 9
Job Address: °� �' �� -3 9 , ` �h �1 , CA Permit #
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Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
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CITY W
CUPEkTINO
CITY OF CUPERTINO
GENERAI. BUILDING
PERMIT APPLICATION FORM
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Date: _ 7 [ ID 0 \
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Building Address:
Mailing Address (if different fro buildin address):
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Owner's Nai -
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Phone #:
HOA: (Exterior work only) Yes (_j No 19
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If yes, provide letter from HOA
Contractor:
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Phone:
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Fax:
Contractor License #:
Cupertino Business License #:
Contact:
Phone: 90S'- .7-572--76q-3
Fax: L4 dS tel? 3- i02S
Residential Commercial ❑
Job Description:
,
Building Permit Info:
— /
Bldg I' Elect Plumb Mech Lid'
Type of Construction (Usage Class):
Occupancy Type:
1-A I -B El II/III/V-A II/III B, IV -HT, V -E, [
A -Z
Valuation: r vO
Square Footage:
Project Size: Express ❑ Standard v, LargeEl
Major ❑
Green Building: Please complete relevant portion c f 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 re !n.or
Revised 02/05/09
CITY OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1STUCOAP
Stucco A:)plications (up to 400 sf)
additiona. stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows)
B
1 WINMEWSTR
New Window -structural shear
wall/masonry (includes plan ck fee)
B
I
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
1 PLMBLNCK
Stand Alone Plumbing Pln Ck (hrly)
P
I STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourly-st end alone
B
1 BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
I BSEISMICR
Seismic ]tesidential
B
1BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
1BUSLIC
Business License
B
IR:kLctvlP.&ce,P
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