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12070135CITY OF CUPERTINO 13UILDING PERMIT BUILDING ADDRESS: 20875 VALLEYGREEN OR CONTRACTOR: KORET FOUNDATION PERMIT NO: 12070135 OWNER'S NANIE: KOREf FOUNDATION 1050 RALSTON RD DA'Z'E ISSUED: 07/172012 OWNER'S PRONE: 4082530200 DEUNIONT. CA 94002 PHONE NO: ❑ LICENSED CC)NI'RACI'OR'S DECLARA'T'ION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. b r r r D1ECIi RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that 1 am licensed wider the provisions of Chapter 9 f JOB DESCRIPTION: APT 22 - WASHER/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. herehy affirm under penalty of perjury are 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 performance of the work for which this permit is issued. Sq, Ft Floor Area: 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 the work for which this permit is issued. ANN Number: 32609064.00 Occupancy Type APPLIC\NI'CF.RTI FICATION I certify that 1 have read this application and stale that the above information is correct. I agree to comply with all 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 the above mentioned property for inspection purposes. (We) agree to save 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 pemnif. Additionally, the upplica t understands and will comply regulations the Cupertino Municipal Code. Section �f with all non-point source per Issued b 9.18, Signature Date RE-ROOFS: All roofs shall be inspected prior to my roofing material being unsalted. If a roof is �. O\VN ER-RIII LIy ISR UISCLAR,\"I'ICIN J installed without first obtaining an inspection, I agree to remove all new materials for 1 hereby affirm, that I am exempt from the Contractor's License Law fur tine of inspection. the fnllmving oro reasons: Las owner of the properly, or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work, and die 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 TO BF, CLASS "A" OR ISM; I-I'F.R construct the project(Sec.7044, Business -Professions Code). I hereby affirm under penalty of perjury one of the following three IIA%ARDOUS AIATF-RL\LS DISCLOSURE declarations: I have read the hazardous materials requirements ander Chapter 6.95 of the I have and will maintain a Certificate of'Consent to self-insure for Worker's California l health S Safety Cade. Sections 2.5505, 25533, and 25534. 1 will maintain Compensation• as provided for by Section 3700 of the Labor Code, for the compliance with the Cupertino Municipal Cade. Chapter 9.12 and the lladth l performance of the work for which this permit is issued. Safety Code, Section 25532(x) should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance, is 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 Hay Area Air Quality Management District 1 will compliance with the Cupertino Municipal Code. Chapter 9.12 and the permit is issued.maintain - Ilcalth S Safety Code, Sections 25505, 25533, and _5534. 1 cenify that in the performance of to 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 Own-Frim authorized age t ColnpetisallOnlu\vsof Cllllfornla. If, after making this Certificate ore.xennpthnn,ICZ� Zo Date:�5ey 2 1 become subject to the Worker's Compensation provisions ofthe Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSfRUCHON LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of smrk's \I'I'I-IC.\N I' CI?It'I'IFICVI'ION 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 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 Lender's Address upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep hamiless the City of Cupertino against liabilities. judgments, DECLARATIONcosts, and expenses which may accrue against said City in consequence of the .\RCIII'1'FCI"S 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 r- lack IS per th ' Cupertino Municipal Code, Section 9.18. Licensed Professional Signauu� Dae � Gf[ , CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION APPLIANCE/ EQUIP TYPE ADDRESS: 20875 VALLEY GREEN # 22 DA'Z'E: REVIEWED BY: Sylvia \ APN: BP#: 'VALUATION: $500 •PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex $134 PENT AMA'I'ION PER111TTYPE: 1RMAP i WORK Washer/Dryer Hook u SCOPE APPLIANCE/ EQUIP TYPE FEE ID Plumb. Plan Check QTY UNITS BP FEES Faac. Permit Fee: Other Appliance/Equip 1BAPPLOT Other F.lcc./nsp. 2 # $134 Pe•tnit-Fee: Suppl. lisp Fee PNIE Unit Fee: $134.00 PME Permit Fee: $45.00 Cousa-uction Tar: Administrative Fee: 1, DMIN $42.00 Work Without Permit? O Yes (D No $0.00 TOTALS: Travel Documentation Fee: ITRA 11DOC $134.00 Strong Motion Fee: IBSEISh1ICR NOTE: This eslitnate docs not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sonitaq• Server District, School District. etc.). These fees are ha.sed on the preliuninary information availahle and are m+b, an estimate. Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053Ii1I 7/1/11) Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Check F1ec. Plan Check Mech. Permit Fee: 1 rb PERMIT Plumb. Permit Fee: Faac. Permit Fee: Other Nlech. Insp. 0.0 hrs$45.00 Other Plumb Insp. Other F.lcc./nsp. ,1 -tech. Inds. Fee: Plumb. lase. Fee: Flee. Insp. Fee: NOTE: This eslitnate docs not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sonitaq• Server District, School District. etc.). These fees are ha.sed on the preliuninary information availahle and are m+b, an estimate. Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053Ii1I 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: SuppL PC Fee PME Plan Check: $0.00 Pe•tnit-Fee: Suppl. lisp Fee PNIE Unit Fee: $134.00 PME Permit Fee: $45.00 Cousa-uction Tar: Administrative Fee: 1, DMIN $42.00 Work Without Permit? O Yes (D No $0.00 Advanced Planning Feer: Travel Documentation Fee: ITRA 11DOC $45.00 Strong Motion Fee: IBSEISh1ICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SU13TOTALS: $267.50 $0.00 TOTAL FEE: $267.50 Revised: 07/01/2012 [all»arli'[i] OWNER -BUILDER DISCLOSURE FORM COhAIdiU1JITY DE�lELO?L. NT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (409) 777-3333 • buiidinct= c_oarino.ora Dear Property Owner(s): An application for a building perinit has been submitted in -your name listing yourself as the builder or the property improvements specified at: SITE ADDRESS ©K APN BP' OWNER NAME. ] i�1 '!/CC./✓ OWN_ ER_ADDRESS� z r y ti zoo �� v.P/fii�n Gj9 9SDl: DESCRIPTION OF WORK: hmz 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 verify this information'.) 5d-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 homeowners 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. ,L2. 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. •S / 3. 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. 5V-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. 45. 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. , 5LI 6. 1 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'contrioute tot unemployment compensation for each"employee." I also'understand my, allure to`ablde'bq these lav s may'subject- me t6.' erious financial risk. �7: 1 understand under California Contractors' State License -Law, an'O�,rier-Builder who builds single-family _residential structures cannot legally build them with the intent to offer themlforsale, unless all v✓ork is performed by licensed subcontra`cto_s and the number of structures does not-ezceed'fou'ry✓ithin any'catendar year,-orall'of the work is performed under contract with a licensed general building Contractor. S %/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 tinancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects, in the workmanship or materials. &nerBuilderForm_2010.doc revised 04/14/10" �w _ �9. 1 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 wvrv✓.csib.ca.gov for more information about licensed contractors. 510. 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. 5 1/ 11. I agree that, as' he party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Ov✓ner-Builders as well as employers. s5JL12. 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 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 tie 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 he 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, 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 to verify the property owner's signature. I Property Owner's Signature: //!>7Ti,1—r!1 Date: ;� -41'/" (NOTE: • The following Authorization Form is required to be completed by the property owner only when designating an agenf of the property owner to apply fora construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF u Ez6ludirig the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my:agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of, Construction Project (or Description of Work): Project1ocation or Address: I E } * ;Name of Authorized Agent Tel No T: I � r a 's i Y-�j i:i_ rf�� I r e J-* .. � � •- ._ , ,y: , r _ Address of Authorized Agent ' ~hdeclare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the -- above;information and c6rtiflviii accuracy. -Note: A,copy of the Property.gwner's drive'r's license, form hotanz66on ofother = venncation acceptable to the city may be required to be presented when the permit is issued to verify the prope ty owner's y — —signature. Property Owner's Signature: Date: OkmerBrrilderForni IOIO.doc revised OQ/I4/IO ... . 12070135 ` CONSTRUCTION PERMIT APPLICATION ` J .- ,` COfvii.4Ui?Ih' Dir=LOFi:1cA:T DE?,IR-j i:LAJT • 'BUILDING DI':rIS100 B 10300 TOnRE rJ/EF1UE • CU?E.'. T C10, Cr', S-901 -'. �2�� CUPERTINO (408) /77'322a -FAX (408) 777-3333 • bttldim(Dcucerino.om ❑NEW CONSTRUCTION ❑ADDCIION ❑ALTERATION/TI I-1 REVISION/D=F -RFD /ORTl:NAT-PMkr1-E pati PROJECT P.OpRES"Z0k25Z� C)re.-erg Z2 3�Z. (�°l •. OWNERNA?�7 /�� /{,/.'1.� PHOKE _O E -MAR STR, T ADDRESS 0 �CX/l. I CIT/. /T^ ZIP . F.4JC t� (✓F,ei") l r. //T /, CONrACr NAMr 1 / PHONE - / O E-MAE SrAET:T ADDRESS '/ CrfY, Sr 28 FAX OwNEic ❑ DWoBt-BZM ER ❑ 0W, ACENr ❑ ccNI Cron ❑ CONTRACFORAGSM ❑ ARCiHTECr ❑ E Cn am ❑ DEVELOPER ❑ TEYANr ' CONTRACrOR NAMEL1111 NUMBER L=SETYPE HUS.ISCO" ' 6j7 COMPANYNAME E -MAH. FAX 2 i LU STAFfi ADDRESS CITY, STAT PHONE t - ` LIQ ' ra 5A- - y ARCHITECUENGD,MER NAME LICENSE. NUMBER .. BUS. LICA COMPANYNAME EMAH• FAX STREET ADDRESS CrrY. STATE• ZIP PHONE DESCRIPTION OF WORK ECTONGUSE - .� - PROPOSED ISE CONSM TYPE 0SrORHSS 4�FF1 EN ox tt,.g'� 'T.2.�mi0� EXISI'G AREA NEWFWCR AREA DEMO AREA TOTAL - NETAAEA - ..v „r „� nv-.�.."M�` a BA'IHItOOM - MODEL AREA R1ZCE@I. OMER REMO t - ipt f 1 10 100— �a�MEM .1 PORCH AREA DECKARPA .'-TOTALDECK/PORCn AREA GARAGEAREi:O AnA� sl. .,, ^ d '-• '�- rDwDl.moutata: aw sscoroaoT - ❑ Yes sscoom crow• ❑ m Bmvcwnam: C] No .ianma<: ❑ Np _ -� £s _ ''.' •.;r - PPS+MPLGYION � TE9' ffVFAPROVIDE COVYoP Fl-VR¢R'SNwhS' y GE1V BY p vy1 °^ TQFAL V.iI. 'iib ,:Ly P..1NNPo APDL/ ip PLtlMAIOAPPROVAL tETIER 5 F By my signature below, I certify to each of the following: I am the property owner or authorized age t to act on the property owner's behalf. I have read this application and the information I have provided is correct I have read the Description of Work and Arify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building conmtpy-ct.on. I a rim representatives of Cupertino to enter the above idenivted property for ivspectim purposes :Signature ofApplicant/Agrnt �� /L�.•-. Date.'/.T•�i�... . .SUPPLEMENTAL INFORMATION REQUIRHb ':--++... .-. L.e•. _ vSfiEe?vykT... ..._ .._nuTiui tm� ;e :- - �"- `=. New SFI)bi Ivfuidfamily dw`ellmgsi�Apply for demolitioa permit for - 'a ezistin buildin s . Dembbhon'e-mtt is re uued g gO p q pnor to iss:aDce ofbuil "adEa�o'�R - ,. IDr'rAtP-v � t � ,-,� permit for new but7ding F, r :. t .,' _ - . , a� XPRFS _ P tl�c r.I.. int - -Commercial t ttr - Bldgs -Provide a completed Hazardous Matrnzls Duclosut-_ � � • ..AanaRn - �a''"G,µ'G ". •fotm if any AHzmdpu"s Materiala`Bre Being used'zs paft'df this p: oject—" ;�, _ ' � ` . -. lA3 LYR x� - _ FlRE11E n Copy of P1anDHtgApproval Lerer or bfeer-tg with P1aDningprior to ; _ �• . '• = '- submittalofBuildingPer;air application. c `L^'oR © s:�vrr RssEw�ROs Enl`IIt S-AIEY t ^ BIdgAIpp_2011.doc revised 03/1 NII .