12070141 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VOLLEY GREEN DR CONT'RACT'OR:20800 VALLEY GREEN DR PERMITNO: 12070141
OWNER'S NAMF,: 20800 VALLEY GREEN DR PO BOX 1368 DA'Z'E ISSUED:07/182012
OWNER'S PDON1i: 4082530200 CARISBAD.CA 92018 1,11ONI,,S0:
❑ LICENSED CON'T'RACT'OR'S DI?CLARATION BUILDING PERMIT INFO: BLDG F- ELECT"r PLUMB r
License Class Lie.k r r r
h1ECH RESIDENTIAL COMp1ERCLV.
Contractor Dale
1 hereby affirm that I am licensed under lire provisions of Chapter 9 JOB DESCRIPTION:APT 508-WASHER/DRYER HOOK UP
(commencing with Section 7000)of Division 3 of the Business& Professions
Code:md that my license is in fall force and effect.
hereby affirm under penalty of perjury tine of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perfomance of the work for which this permit is issued. Sy.Ft Fluor Area: Valuation:$500
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfomtance of die work for which this
permit is issued. AI'N Number:32609040.00 Occupancy Type:
APPLICANT CERTI FICVfION
I certify that I have read this application and state that the above information is
correct.l agree to comply withadl city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
Upon theabove mentioned property for inspection purposes. (We)agree to Saye WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence Of the
granting of this permit. Additionally,the applicant understmids and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by.: Date:
9.18.
Signature Date
RF;ROOFS:
19 OWNER-BUILDER DECLARATION' All roofs shall be inspected prior to any rooting material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I heresy affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date.
will do the work,and the structure is not intended or envied for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sce.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS NIATIMAI S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter(.95 of the
1 have and will maintain a Certincatc ofConsent to self-insure for Worker's California Health&Safety Code.Sections 25505,25533.and 2553.1. I will maintain
Compensation,as provided for by,Section 3700 of the labor Code,for the compliance with the Cupertino NI unicipal Code.Chapter 9.12 and the Ilcal th&
perfomance of the work for which this pemtit is issued. Safety Code.Section 25532(a)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous Air
Section 3700 of the Labor Code,for the.performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I is ill
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
lealth&Safeh'Code.Sections_5505,25533,and 25534.
1 certify that in the performance of the work for which this pemtit is issued.I shall
not employ any person in any manner so as to become subject to the Worker's 0 vMr or nnth rueda nit:
Compensation laws of California. If,other making This certificate Ofexemptirnt,I / Dnic�l/ l�L
become subject to the Worker's Compensation provisions of the Labor Code.I 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 work's
APPLICANT CERTI FIC TION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct. I ugree to comply with all city and county ordinances aid state Imus relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCIII'I'IiCI"S DECLARATION
costs,and expenses which may aceme against said City in consequence of the
granting of this pertain.Additionally,the agtplic:ml understands and will comply I understand my plans shall be used as public records.
with all non-point Source regulall.ons per c Cupertino Municipal Code,Section
9.18. Licensed Professional
Signatur D•atc � �
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20800 VALLEY GREEN # 508 DATE: REVIEWED BY: Sylvia
\ APN: RP#: IVALUATION: $500
*PERMIT TYPE: Mechanical Permit PLAN CIIECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAIIIATION
USE: SFD or Duplex PERMITTYPE: 1RMAP1
WORK Washer/Dryer Hookup
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 1BAPPLOT 2 # $134
TOTALS: $134.00
Mech. Plait Check 0.0 1 hrs $0.00 Plumb. Plan Check Flee.. Plan Check
Mech. Permit Fee: IMPERMIT Plumb. Permir Pec: Flee..Permit Fee:
Other Mech. Insp. 0.0 lies L$45.00 Other Plumb lisp. Other Elee.Insp. Ll I
,1•Icch.lisp.Fee: Phooh. lay.Fee: Lice.hup.Fee:
NOTE: This estinuae does not inchulefees due to other Departments(i.e. Planning, Public Works, Fire,Sanitaq,Sewer District.School
District, etc.). These ees are based on the prefintinan•information available and are onh'an estinune. Contact die Dept far addn'I info.
FEE ITEMS (Fee Resvohaion 11-053 Efl: 7/l/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Sapp!. PC Fee
PME Plan Check: $0.00
Permir Fee:
SupPL /asp Fee
PME Unit Fee: $134.00
PME Pennit Fee: $45.00
Consnvction Tax.-
Administrative
ar:Administrative Fee: /ADMIN $42.00
Work Without Permit? 0 Yes Q No $0.00
Advanced Planning Fecs:
Travel Documentation Fee: ITR.11'DOC $45.00
Strove Motion Fee: IBSE1SHICR $0.50 Select an Administrative Item
131d]" Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $267.50 $0.00 TOTAL FEE: $267.50
Revised: 07/01/2012
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO„CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333 • buildinCra)Cuoertino.orC
Dear.Property Owner(s):
An application fora building permit has-been submitted in'yodr name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS //� /' eh c API 2�[ D�jO BP^
OWNER NAME ( OWNER ADDRE/ (7
21
DESCRIPTION OF WORK: 1
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
— - - your responsibilities and possible risk you may incur by having this permit issued in your name-as the Owner-Builder.-We___
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
V. -1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder” building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
S ✓ 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
SJL3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
J/� 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an"employer" under state and federal law.
5d/-6. I understand if I am considered an"employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
3 if 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
V 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
0lrnerBuilde!'Forn] 2010.doc revised 04/14/10
understand I ma'y obtain:m:ore Iniwrn:2ilon regarding my oblioaxions as an "emplovef from the lnternal
lRevei:!ja Service, the united Siaies Small Business A-dm(n;s*Fafto:n, the California Dop2iiment of BerieHt Paymenis,
and the California Division of Ind!s vial.-'.ccidsns. I also Li-lda,stand I may coniact the California Contractors' Sicie-
License Board (CSLB) 2t 1-800-321-CSL3 (2732) or v^r^✓.csib.ca.gov for more information about licensed
contractors.
5 I) 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and nnancially responsible for proposed construction activity at the site address listed above.
.5 V_1 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I Will abide
by all applicable lays and requirements that govern Ovrner-Builders as well as employers.
a/ '12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any or the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
:you contract with someone who does not have a license, the Contractors' State License Board may be unable to
:assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
:you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.) :
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.)
Lender Name: - Lender Address:
Before a building permit can be issued, thisform must be completed and signed by the property owner and ;
returned to the agency responsible for issuing the permit. Note:A copy of the.properly owner's driver's license,
form notarization, or other verification acceptabie to the city may be required to be presented when the permit is issued
io verify the property owner's si nalure.
Prgparty Owner's Signature: — O> Date: _//7. '
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:(NOTE:'•Tha,follov✓ing Authorization Form is required to be completed by the property owneronly when designating an
'';agent of th'e properly owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I.understand is my personal'responsibility, Thereby
r.'authonze the following persons)to act as.my.agent(s)jo apply for, sign, and file the documents necessary to obtain an
Owner Builder Permit for my project.
...,.:..
.; ScQpe`of.Coilstruction Project(or Description of,Work):
Location or Address:
it
r Name ofAuthozed Agent? a . Tel No
n }y
QST si frJi
unze * x '
Address ofAthod'Agent - t E
,• _k may. -- . .� : . ... .. , . - -.: :,• " , � n .
e v�decla�erunder penally of-perjury that I am the property o4✓nedtor the address listed above and t personally filled out the'
abotve a formation and;ceru y its:accuracy:_No A_;coPy of thepll '-e t..oyi;ier!s driver's license form noianzaGon or,oJ er z .
t
?' ' venncation acceptable to the citymay be required to So presented when the permit is issued to verify the propeYy
.-• -signature-'- --.—
Property Owner's Signature: Date:
MtOil
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CONSTRUCTION PERMIT APPLICATION
COivlieiUl'ITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO,CA 95015-3255 --
(408)717-3228 • FAX(408)777-3333•b6i[dinn@cuoerflno.org
Cili?�E2'YI;iS3
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERA.170N1.7I ❑ REVISION/DEFERRED ORIGAA.L PE=•'.
PROIECT ADDRESr //�� //j ( C�
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DESCR M6T OF WORK
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By mysigtature below,I certify to each ofthe following: I am the property owner or au. Om agent to act on the property owner's behalf. I hive read this.
anpticadon and the information I love proved d is coRecL I have ren the Description of Wok and verify it Ls'accvmte I agree to comply with all applicable local.'
ordinances end stare laws rela=9 to ding con ctioa I atnty representatives of C _rtino to enter the abbve-identified property for mspecugn purposes.
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SUPPLEMENTAL`INFORl1ATI0NRE.�}rrr� -�- .
New SFD of MuItlfamt]y dwellrags Apply for demolition permit for' .� � ;r< .�.� '�- „� ;�
pasting btDldmg(s): Demolition perm,t u regtl:red prior to issuaDce ofbvildm � •a"-r - �•^�'.d� :�' � t''m' 1 � w '� -
certT_ICfornew.btlrlding. { - -- - - gr ': -t6} ^M •F v 2` r+H r'.
_CommeiLial Bldgs Provtde a completed Ez<ardous Materiels Dsclostue s�-�, —
V- � �- 11BBt1rFv—r` - -
iorm if eny Aazadoes Materials ere being csed aspart of this project - ''" � -a .�
Copy of Plannitg Approval Letter or Meedag with Planning pr'or to - '���� � �.-. ��w� '
sebmittal of Building Permit application. _EAv .�' -" Y "E -{ •
• - -• Bldpipp'2011.doc revised 03/16111 -