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12070137CITY OF CUPERTINO BUILDING PERMIT RUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRAC'MR: KORET FOUNDATION PERMIT NO: 12070137 OWNER'S NAME: KORET FOUNDATION 1050 RAISI'ON RD DA'Z'E ISSUED: 07/172012 OWNER'S PlIONE: 4082530200 BELMONT. CA 94002-2243 PIIONE NO: ❑ LICENSED CON'fRA(—VOR'S DIiCLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class l'ic. t! r b1ECH RESIDENTIAL _ COMMERCIAL Contractor Dale hereby affirm that Iran licensed under the provisions of Chapter 9 JOB DESCRIPTION: APT 294 - WASIIGR/DRYER HOOK UP (commencing with Section 7001) of Division 3 of the Business & Professions Code and that nn• license is in full force and effect. hereby affirm under penalty of perjury one of the following ro 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 performance of the work for which this permit is issued. Sq, Ft Floor Area: Valuation: $500 I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of die work for which this APN Number: 32609041.00 Occupancy Type: permit is issued APPLICANT CERTIFICATION I certify that I have read this application Enid state that the above information is correct. l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK ISNOT STARTED to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property, for inspection purposes. (We) agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the Cily of Cupertino against liabilities,judgmems, 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 understands and will comply CnpeuiaO Municipal Code, Section �7 w'Ith all non -point source regulations per the Issued by 9.18. Signature Date RF: R00FS: All roofs shall be inspected prior to any roofing material being installed. If a roof is OWNER-BUI LOF:R DECLARATION installed without first obtaining an inspection, I agree to remove all new materials for hereby affirm that I am exempt from the Contractor's License Lim fur one of inspection. file following boo reasons: I, 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 offered for sale (Sec. 7044, Business S Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to ALL ROOF COVERINGS] 0 BE CLASS "A" OR BETTER construct the project(Sec.7044, Business R Professions Code). herchy affirm under penalty of perjury one of the following three IIAZARDOIIS NIATERIALS DISCLOSURE.. declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self -insure for Worker's California Ilealth & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain Compensation, as provided for by Section 3700 of the Labor Code, for the compliance with the Cupertino Municipal Code. Chapter 9.12 and the Ilealth & performance of the work for which this permit is issued. Safety Code. Section 25532(n) should 1 stare or handle hazardous material. I have and will maintain Worker's Compensation Insurance, as provided for by Additionally, should I 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 1 will permit is issued. maintain compliance with the Cupertino Municipal5534. Code, Chapter 9.1'_ and the S 255 I lealnh & Safety Code, e tions 05, 25533, and _ I certify that in the performance of tic work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's O per nr an urizetb run: � mu Compensation Is ofCaliforia. If, after making this cenificate of exemption, I � � Date: Z 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 CONSTRlICf10N LENDING ACF-NCY I hereby affirm [hill there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued (Sec: 3097, Civ C.) I certify that I have read this application and stale that the above information is Lender's Name correct. I agree to comply with all city and county ordinances and state laws relating to building construction, arid hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes. (We) agree to save indenaily and keep harmless the City of Cupertino against liabilities, judgments, costs, unit expenses which may accrue against said City in consequence of the ARCI I I'fECI"S DECLARA'T'ION granting of this permit. Additionally, the applicant understands and will comply I understand my plans shall be used as public records. with all non -point source regulations pe the Cupertino Municipal Code, Section 9.18. Licensed Professional Signature _ Date W CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION W[,71DDRFSS: 20975 VALLEY GREEN # 294 DATE: REVIEWED BY: Sylvia UNITS BP FEES BP#: 'VALUATION: $500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARYSFD or Duplex USE: $134 PENTAMATION 1RMAP1 PERN117'Tl'PE: \\'ORK Washer/Dr er Hookup SCOPE APPLIANCE I EQUIP TYPE FEE ID Plumb. Plan Cheek QT\' UNITS BP FEES Flea Permit Fee: Other Appliance/Equip 1BAPPLOT Other Elec- Insp. 2 # $134 Permit Fee.: Suppl. Msp ree PME Unit Fee: $134.00 PME Permit Fee: $45.00 Cots•trllcdon Tac: Administrative Fee: IADMIN $42.00 Work Without Permit? O Yes (E) No $0.00 TOTA LS: Travel Documentation Fee: ITR,UKDOC $134.00 Strong Motion Fee: 11ISF-1SMICR NOTE: This estinutte does not includejeev due to other Departments (i.e. Planning, Public Work's, Fire, Sanitary Sewer District, School District. etc.). Theve fees are based an the nrelintinun• information available and are only ant estimate. Contact lite Dent for at/dn'I info. FEE ITEMS (Fce Resolution 11-053 Eff 7/1/11) Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Cheek Elec. Plan Check Mech. Permit Fee: IMPFRMIT Plumb. Permit Fee: Flea Permit Fee: Other Mech. Insp. 1 0.0 hrs $45.00 Otter Plumb lncp.El Other Elec- Insp. Mech. hasp. ree: Plumb. htsp, Fee: Elec. Insp. Fee: NOTE: This estinutte does not includejeev due to other Departments (i.e. Planning, Public Work's, Fire, Sanitary Sewer District, School District. etc.). Theve fees are based an the nrelintinun• information available and are only ant estimate. Contact lite Dent for at/dn'I info. FEE ITEMS (Fce Resolution 11-053 Eff 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check ree: Strppl. PC ree PME Plan Check: $0.00 Permit Fee.: Suppl. Msp ree PME Unit Fee: $134.00 PME Permit Fee: $45.00 Cots•trllcdon Tac: Administrative Fee: IADMIN $42.00 Work Without Permit? O Yes (E) No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITR,UKDOC $45.00 Strong Motion Fee: 11ISF-1SMICR $0.50 Select an Administrative Item I31de, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $267.50 $0.00 TOTAL FEE: $267.50 Revised: 07/01/2012 t'. 0"ISER"BUILDER DISCLOSURE FOPM 6 COMMUWI i / DE`:/ELOPM.ENT DEP.k.DTIAENST • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 4501=-3255 CUPERTI NO (408) 777-3223 • FAX (?03)777-3333 • wiidin�8c_oa i�os= Dear Property Owner(s): An application for a building permit has been submitted in -your name listing yourself as the builder of the prooerty improvements specified at: Sri E ADDRESS 2N. APN 0 V � 32 6 LQ 220 BPS OWNER NP.AAE OWN R ADDRESS DESCRIPTION OF WORK: ✓� 'K 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. EDGMENT AND VERIFICATION OF INFORMATION read and initial each statement below to signify you understand or verity this infor riation.) 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. &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. 3JI 3. 1 understand'as an "Owner -Builder" I am the responsible party. of record on the permit.) 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 myown. V4. I understand Contractors are required by to be licensed arid bonded in Califomia and to list their license numbers on permits and contracts. _�Z5. I 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 maybe considered an "employer" under state and federal law. �) understand If I am consldered'an "employer" under state and federal law I`mKus regisrter with the statte and federal government wlthhold'payroll taxes, proylde workers compensation dlsablhfyln'surance and cos tribute toL; '.. � ' r �7. 1 understand under California Contractors' State License'Law an Owner BuiIderwhD builds smgle-family residential structures cannot legally build them with the intent to o er inem for sale;'unless all vJork is pe forrrled by licensed subcontractoFs and the number of stfu tures does not exce-ed four within any -calendar year, -6r all of the work is performed under contract with a licensed general building Contractor. ,5-18 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for r. .� any filiancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction , defects In the workmanship or materials. ly �`�,��+` TT y -•` � - s —' _, � ' x ��O�mertr<ilderFor� 2010 doc i ewsed Os/19/10: 3 ' V-9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal .Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cs[b.ca.gov for more information about licensed contractors. 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 financially responsible for proposed construction activity at the site address listed above. ,511. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. •;512. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of 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 riot 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 Owrier-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: tender Address: .. i.:'..:.. '.'(NOTE agent c a building permit can be issued, this form must be completed and signed by the property owner and d to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, tarization, or other verification acceptable to the city may be required to be presented When the permit is issued the property owner's si nature. i Owner's Signature: Date: ----------------------------------------------- ------------------------------ The,following Authorization Form is required to be completed by the• property owner only when designating an ' e property owner to'app/y fora construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF g'the Notice to Property Owner, the ekecution of which I. rnderstand is my personal responsibility, I hereby a the following person(s) to act as.my`.agent(s) to apply for, sign, and file -the documents 'necessary to obtain an Wilder Permit for my project. f,Cohstruction Project (or Description of Work): or to the city may ferry Owner's Signature: the'property ov✓ner•for the address ligt NQte.A;copy,of the property owner s'c rquired to 6e presented ah an the perp Date: s i- tlA:! -e,_"-* —,W. -'` . qviwerBuilderFomi 2010._docisd04/14/10 — r , I rz o-7 of 3-7 Ell CODSTRUCTION PERMIT APPLICATION i CObiFa UA;ITt' OE'IELGFi:iEkT DE?.=.?Tiri=i•;T •cU: L�CIPIG ul':riCi1Gti 10300 TORRZE AVENUE - CUPER T ENO, C ` -h-- r'. Scn =-;255 CC U P ERT 1 N9N9 (A.08) 777-3228 • FAX (4108) 777-3533 - buildirc(GDcuoertiraora 1 IIVEW CONSTAU=ON I I AMMON ATTFRATMIJ) i F-1 RFVi.CTI?i/IIF.TRRFTI I1RV:NAT PRor_cr ADOIUs- ZQ%7 s{{,.�.�/�%/ f�✓P��l/ ff' � /tj I A2No -� O/0 �/Y . OWNER NAME J,( OyI� oI 1 L T I f Jt/ ,HOK. 5'Pi:s—tADDAESSY2� O l/ (� %< .M • /, CPP!.m"// �1 Q // s-eglF.4X AMI,--, CONPAR NAME - BATHROOM B.cf MEET ADDRESS/ OliiEt( CIN, 417 TE. 2II' .'•RFMODELAREA•r+. FAX REMOD6 AREA :. mRCH AREA DECK ARPAI�:_ ::TOTAL DECRE'OAQi AREA', :�GAAP.GE AREA: MACH kfOWNFA ❑ OWNER-R=m ❑ OWNEtAGENT ❑ CONTti ACTOR ❑COMB MXAGENT ❑ ARCMma ❑FNGmB ❑ DE OPER ❑TENAM ' CONTRACrOR NAME' LICEKSENUMBER43(!)( 'IO LICENSETYPE� BUS. LIC 9•. . COMPANY NAME' ^ E-MAII. FAX STREET ADDRES�DO ltl •�1 ( I •l .Cu4 CIPY, TE ZIPI d PHONE l _ qk y`11- n I J `, •t la- ARCHPPECDENGB�FiNAME PPS-MPLCA}ID.Y. LICENSE NUMBER BUS. LIC M . AMI �A.VUIPA _ zo• APPROYAL.IEREt .. .. .. COWNAME •SSREEP ADDRESS DESaup- ION OF WORK E -MAB. CITY. STA7E.78 r:xisQag buildwg(s)'' Demollhoa pemvturequued pnor toIssuanceofbuddmg- � EATEmtGUSE .l - PROPOSEDmE •co=TYPE osm= E =G r - Commemal Bldgs Provide a completed Hazardous Matenals Dlselosur NEW FLOOR � DEMO TOTAL AREA �.� AMI,--, AREA NETAREA BATHROOM _ KTPCHEN �.. _ OliiEt( REMODEL AREA. .'•RFMODELAREA•r+. :. i�. REMOD6 AREA :. mRCH AREA DECK ARPAI�:_ ::TOTAL DECRE'OAQi AREA', :�GAAP.GE AREA: MACH .LC �.J:\?: :i"; . .: S ::1. : ❑ ATTACH ATTACH IDWFIIMUIMQS -6ASCC0[3llrvTr"••., QY6 SECOtm 51'DAY ❑YE5 . BF.➢'ICA➢➢IDi: ❑NO' AD➢[RWt.- ❑NO PPS-MPLCA}ID.Y. ❑ -FYERPR1PLMTRbDVIDE COPI'W.: PI.1M.'R'SN �L. . AMI �A.VUIPA _ zo• APPROYAL.IEREt .. .. .. r:xisQag buildwg(s)'' Demollhoa pemvturequued pnor toIssuanceofbuddmg- � pemv for ne bail . � �+, �: r• + a; . ,. - �� s `• w . ._ . r - Commemal Bldgs Provide a completed Hazardous Matenals Dlselosur `tormif any Hazardous Ma*enals ai 'bemg used a pall of tfiis project."' " �.� Copy of Plaanmg_Appmval Leser or'Me.dng with Planningprior to �t+.rn 'submitta]ofBuildmg Pemut apphcahpD. - _ 2 FAX PHONE ME