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12070136CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 20975VALLEYGREENDR CO\I'RACI'OR: KORLT FOUNDATION PERMITNO: 12070136 OWNIiR'S NAME: KORET FOUNDATION 1050 RALSTON RD DATE ISSUED: 07/172012 OWNER'S PHONE: 4082530200 BELMONT. CA 940022243 PliONENO: ❑ LICENSED CON'TRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUNIR License Class Lie. k r r r pIECH RESIDENTIAL COMMERCIAL Contractor Date I herehy affirm that 1 am licensed under the provisions of Chapter 9 .1013 DESCRIPTION: APT 207 - WASDER/DRYER HOOK UP (commencing with Section 7000) of Division 3 of the Business S Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the fullorcing ben 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, I'or the pedor n ince of (lie work for which this permit is issued. S Ft Fluor Arai q Valuation: $500 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of toe work forwhich this APN Nu in her: 32609041.00 Oce upa Rey Ty pe: permit is issued. APPLICANT C1; RTI FICAT1ON I certify that I have read this application and state that tine above information is correct. I agree to comply with all city and county ordinances mad state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED t0 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 kap harmless the City of Cupertino against liabilities. judemenTs, 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 with all non -point source regulations per the Cupertino MnnlClpal Code, Section Issued b Dale-7-Xq —rZ 9.18. Signature Date RF: ROOFS: V OWNER -BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtainine_ an inspection, I agree to remove all new materials for 1 hereby affirm that I am exempt from the Contractor's License Law for one of inspectim, the following bob reasons: I, as owner of the propeny, or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work, mid the structure is not intended or offered for sale (Sce.7044, Business R Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to AL1. ROOF COVERINGS TO RE CLASS "A" OR BETTER construct the project (Sec.7044, Business R Professions Code). hereby affirm under penalty of perjury one of the foll(ming three IIA''/.ARDOUS MA TFRIAIS DISCLOSURF. 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 Ileakh S Safeb' Code. Sections 25505. 25533, and 25534. 1 will maintain Compensation, as provided for by Section 3700 ofthe Labor Code, for the compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health S performance of the work for which this permit is issued Safety Coda Section 25532(a) should I store 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 time Labor Code, for the performance of the work for which this contaminants as defined by the Bay Area Air Qua lily Managenm eat District I will permit is issued. p maintain compliance with the Cupertino Nl unici pal Grade. Chapter 9.11_ and the Health S Safety Code. Sections 25505, 25533, and 25534. 1 certify that in the performance of the 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 i r or auth ized C G 7/1z Compensation Imes of California. If, after making this certificate of exemption, I Date. become subject to the Worker's Compensation provisions oRhe 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 A I'I'IiICAN'I' CI?IC'1'I FIC,\'1'ICIN 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 Leader's Name correct. I agree to comply with all city and county ordinances and state laws relating to building construction, mid hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes. (%%'e) agree to save indemnify and keep harmless the City of Cupertino against liabilities. judgments, costs, and expenses which may accrue against said City in consequence of the ARCI I I"fFCI"S DECLARATION 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 regulmmns p the Cupertino Municipal Code, Section 9.18• Licensed Professional i Signat v� i )ate i/ l 2. CUP ERTI NO GAINER -BUILDER DISCLOSURE FORM COMMUNITY D --V--1 OPMENT DE PAID T MENIT • BUILDING DIVIS-ION 10300 TORR -E- AVENUE - CUP=RTINO, C.4 95014-3255 (408) 777-3223 - FAX (409) 777-3333 • bviidina�:.. JDar'.i:1 �.o�a Dear Property Owner(s): An application for a building permit has been submitted in your hame listing yourself as the builder of the property improvements specified at SITE ADDRESS APN -> 19 � BPm OWNER DESCRIPTION OF WORK: 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. (DIRECTIONS: Please read and N Lit- INYUKIVIA I IUN . . below to signify you understand or verify this information.) 5111. 1 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. I 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. . 511'3. 1 understand as an "Owner -Builder" I am the responsible party, of.ecoid 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 my own. 5 G�4.1 understand Contractors are required by to be licensed and bonded in California and to list their license numbers on permits and contracts. 5—V-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 matenals,:l may be ".Y considered an "employer" under state and federal law:' _ r 6 (understand if 1 arrcorisidered an "employer' under state and federal law I must regls c,wlth the state and federal government withhold payroll taxes, proylde worke s compensat on dlsabllltyinsurance' and contrl6ute to r unemployment compensation for each employe Ialso understand myyfai�lu_re to abide by these laws may�sub)ect ='me toseriou`s:financial risk--'-- , 17, µSl�7. 1 understand under California Contractors' State Llcense'Lav en OwnerBuilderwho builds smgle,fgmlly .residential structures cannot legally build them with the intent to offer themforsale� unless,a/lv✓oricis'perforrrledby __ I _ licensed subcontractors and'the number of structures does not exceed four v✓ithin-any calendar year,'orall of the work is performed under contract with a licensed general building Contractor. 8._I understand as an Ov✓ner-Builder if I sell the proparty for v:,hich this permit is issued, I may be held liable for a . any Imancial orpersonal injuries sustained by any subsequent. owner(s) that result.from any latent construction rdereots In the workmanship or materials. s 1: 5IL9. 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.csib.ca.gov for more information about licensed contractors. 110. 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. .5tl 11. 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. 12. 1 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 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 Owher-Builder and wish to hire Contractors, you will be responsible for verifying whether or not Fthose 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 he'rebyaffirm 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, this form must be completed and signed by the property owner and..'. returned to the agency responsible for issuing the permit. Note._ A copy of the property owner's driver's license, form_ notarization, or other verification acceptable to the city may be required to be presented when the permit is issued Property Owner's Signature r—:? //�7yJ� Date: �'/t '/ _ i;. (NOTE; •The following'Authorization Form is required to be completed by the property owner only when designating an agent of ttiie property owner to apply for a'eonstruction permit for the Owner -Builder). Notice to Prop following perso r Permit for my Owner, the execution of which 66nderstand is my personal responsibility, I hereby to act as.my:agent(s) to apply for, sign, acid file the documents necessary to obtain an,' iction'Project (or Description of, Work): or Address: i ed Agent r x� � s •�•>x- • 't• .nalty,of perlury':that I am the propertyowner,forthe address 1 "i a&ffiaation acceptable to the city may be requirer _signature. Property- Ov✓ner's Signature: ��. r '' p.gif�ui t ` rI ' be presented when Date: O�swerBuildv,Form_2010docy, viseJ04/14/]0 � — CITY OF CUPERTINO r"I FEE ESTIMATOR -BUILDING DIVISION JAI ADDRESS: 20975 VALLEY GREEN # 207 DATE: REVIEWED BY: Sylvia UNITS APN: BP#: 'VALUATION: $500 *PERMIT TYPE: Mechanical Permit PLAN CIIFCK TYPE: Alteration / Addition / Repair PRIi�IARI' USE: SFD or Duplex $134 PENT.I�IATION PERIIIITTYPE: 1RMAP WORK Washer/Dryer Hook u SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check Q'1'1' UNITS BP FEES Flee. Permit Fee: Other Appliance/Equip 1BAPPLOT Other Elec. Insp.Ll 2 # $134 Permit Fee.: Suppl. Insp Fee PME Unit Fee: $134.00 13M Permit Fee: $45.00 Constt7tCliom %tiv: Administrative Fee: IAD,MIN $42.00 Work Without Permit? O Yes 0 No $0.00 TOTALS: A Travel Documentation Fee: ITRAI'DOC $134.00 Strong Motion Fee: IRSFISaMICR NOTE: This estintvte does not include jeer due to other Departments (i.e. Planning, Public (Yorks, Fire, Sanitary Seiner District, School District, etc.). These feev are based on the reliminnrl information available and are onlr an estimate Contact the Dept for athln7 in t, FEE ITEMS (1'ee Resolution 11-053 E0 7/1/11) Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Check Flee. Plan Check Mech. Permit Fee: IMPERMIT Plumb. Permit Fee: Flee. Permit Fee: Other Mech. Insp. 0.0 hrs $45.00 Other Plumb Insp. Other Elec. Insp.Ll ,Mech. lap. Fee: Plumb. buy. pee: Elec. Insp. Fec: NOTE: This estintvte does not include jeer due to other Departments (i.e. Planning, Public (Yorks, Fire, Sanitary Seiner District, School District, etc.). These feev are based on the reliminnrl information available and are onlr an estimate Contact the Dept for athln7 in t, FEE ITEMS (1'ee Resolution 11-053 E0 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: SuppL PC Fee PME Plan Check: $0.00 Permit Fee.: Suppl. Insp Fee PME Unit Fee: $134.00 13M Permit Fee: $45.00 Constt7tCliom %tiv: Administrative Fee: IAD,MIN $42.00 Work Without Permit? O Yes 0 No $0.00 Advance(/ Plumtinb Fees: A Travel Documentation Fee: ITRAI'DOC $45.00 Strong Motion Fee: IRSFISaMICR $0.50 Select an Administrative Item I31de Stds Commission Fee. ISCSSC $1.00 SUBTOTALS: $267.50 $0.00 TOTAL FEE: 1 $267.50 Revised: 07/01/2012 CONSTRUCTION PERMIT APPLICATION I COFDEP::.AR T HENT - EUI -DING DI'dIS!Oh1 i 0300 TOR; :c :.VcNUE • CUFERTI; lO, Com. S -H) i-'.-32195 CUPERTINO (408) 777-3228 • FAX (4.08) 777=3333 • buildirG(r)cuoerino.o o ❑ NEV CONSTRU=C)N 7 ADDITTON n a1TFYATtnVln I-1 nrrncrnv 111 11 1Z0-7vi 3(-D PROTECT ADORES" ©C &Ile- Ckeen At 26 a2 0 y -1/2 _ OWNERNAME RL 1 .N PHO`O S3 -0,>`I1 _-MAL ST -Ra -'r ADDRESS STATE• ZIP AX CONTACT NkME / ' LICEITSETYPE PHONE/ 6 COMPANY NAMEAM R Q mo STREET ADDRESS _6010 CRY SfiTE, ZII` G L FAX t - if CITY. Sr E. ZIP R 10 ined 9{ - OWNER ❑ OWNER-DUHDER ❑ OWMACENT ❑ CONTRACTOR ❑ CONTRACTOR AGENr ❑ ARCETTECT 0 MG R ❑ DEYFI.DPER ❑ TENANT ('CONTRACTOR NAME' REMDDEi AREA . �.a.Tax -z^ = _ LICENSE NUMBER - am ' LICEITSETYPE HUS. TSC S ' COMPANY NAMEAM R Q mo -A4 54 5ow =E-MAILFAX . u. i; ' STREET ADRESS PR6�PPPLCAi1tp1 . CITY. Sr E. ZIP R 10 ined 9{ - bT PHONE 562 -/ i0 0 ARCHRECLEIJGAlEt7t NAME Z 4 LICENSE NUITRER BUS. LIC a ' COMPANYNAME E NIAIL-. .• FAX STREET ADDRESS CRY. STATE, ZIP PHONE DESCRIPTION OF WORK iaw tinHdi: vci FXLSTG AAFA ONA NEW FLC BATHROOM AREA _ •. R REMDDEi AREA . �.a.Tax -z^ = _ -R POACHAA&1 DEC, AREA: ,DWELA6UNIIS . u. i; ac PR6�PPPLCAi1tp1 . ❑TES' • ff l 'flAMRlO APDL, O1IJ" •PU ,By my signature below. I altif D ISE CONSRC TYPE 6 STORIES DEMO TOTAL ' AREA NETAAEA OTHER 2AREA•.-., .. *:. .REMODEL AREA :. ' rTAL D_ ECWR1R03 AREA.;GARA(Ei AREA:'❑ DETACH ❑ ATTACH rD IL�TS"':::Q V6 5[COCb SiO11Y ❑YES ' iini. ...'0 Ero•, .Inorrim:.: ❑No VIDE COPYOF,; .S PLWlh4'S NAI.. . VPHOVAGLF!}Et ch of the following: .1 am the omoei tv I Copy ONA ofPlaanTng:Approval Letter or Meenno with PlRnaing prior to -n • ,_ ' submlttaI Dliu a' Ycrmlt application. �.a.Tax -z^ = _ - -.5A•=-�.�w- �D`ON .,yah......' EJ37ROjlTEtelT! Bldg4pp 1011 docrel;c Z 4