12080184CITY OF CUPERTINO BUILDING PERMIT
BUILDINC ADDRISSS: 20975 VALLM' GR1;1-N DR
OWNER'S NAM E: KORE'f FOUNDA'T'ION
O\YNER'S PHONE: 4082530200
❑ LICENSED CON'TRACTOR'S DECLARATION
License Chas Lie. 4
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Di%isiun 3 of the Business J Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjure one of the following two declarations:
1 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of Utc work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state Imus relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs, and expenses which may acerae 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 Municipal Code, Section
9.18.
Date
0V OWNER -BUILDER DECLARATION
I hereby affirm that I ilia exempt front the Contractor's License Lane formic of
the following two reasons:
I, as owner of the properly, or my employees with wages as their sole compensation,
will do the work, and the swcture is not intended or of tend for sale (Sec.7044,
Business K Professions Code)
1, as owner of the property, ran exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
hereb%y affirm under penalty of perjury one of the following three
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.
I 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.
I certify that in the performance of die 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
Compensation Imus of Cali fomia. If, alter making this cnnilicate ofesemption, 1
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be dL'ellled revoked.
APPLICANT CERTIFICATION
I certify that I have read this application and state than 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 properly for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accme against said City in consequence of the
grunting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulationsp the upenino Municipal Code, Section
9.18. ��
Sinnnnne� 1/�A// �(/ `Q Date %;
CONPRACI'OR: KORIETFOUNDATION PERMITNO: 12080184
1050 R,U.S'fON RD DATE ISSUI.D: 0811612012
B EILMONT,CA 94002-2243 PIIONENO:
BUILDING PERMIT INFO: BLDG C ELECT r PLUMB I-
NIECII r RESIDENTIAL 1— COMMERCIAL r.—
JOB
JOB DESCRIPTION: APT 206 - INSTALLATION OF WASHER AND DRYER
HOOKUPS
Sq. Ft Floor Area: I Valuation: $500
APN Number: 32609041.00 I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: �� /✓ %y/7 Date: z '-z -ld—
RE -ROOFS:
All roofs shall be inspected prior to any roofing material beng installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:_ Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BE ITER
IIA%ARDOIIS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safetv Code, Sections 25505.25533. and 25534. 1 will maintain
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health S
Safety Code. Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit huardous air
contaminants us defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
Health S Safetv Code, Sections 25505, 25533, and 25534.
or nnthorr J ager /fir .� . -
Jy `� 1 .Date:.
CONSTRUCTION LENDING AGENCY
I hereby aBinn that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCIITTECI"S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
NOTE: This ertinmte does not include jeer slue m other Departments (i.e. Planning, Public Works, Fire, Sunimry Server District, Schaal
District, etc.). These fees are hared on the prelintinarr information arailahle and are only (tit ectinmte Contact the Dept for aaldn'I info.
FEE ITEMS (Fee Resolution ll -053 Elf. 7/171 U
20975 Valley Green #206
DATE: 08/16/2012
REVIEWED BY: Sean
iaADDRESS:
APN:
BP#:
-VALUATION:
$500
*PERM1TTYPE: Building Permit
PLAN CII ECR TYPE: Alteration/Repair
PRIMARY
USE: Multi -Family Dwelling
Buildina is
>3 Stories O Yes O No
PENTAMATION
PERMITTYPE: 1RMAP
WORK
Installation of washer and dryer hookups.
SCOPE
$0.00
NOTE: This ertinmte does not include jeer slue m other Departments (i.e. Planning, Public Works, Fire, Sunimry Server District, Schaal
District, etc.). These fees are hared on the prelintinarr information arailahle and are only (tit ectinmte Contact the Dept for aaldn'I info.
FEE ITEMS (Fee Resolution ll -053 Elf. 7/171 U
Mech. Plan Check E.0 hrs $0.00
Plumb. Plan Check
Elea Wan Check
Mech. Permit Fee: IMPERMIT
Plumb. Permit Fee:
Elec. Permit Fee:
Other Mech. Insp. 0.0 hrs $45.00
Other Plumb /asp.
Od er 61ec. Insp.El
ddech. htap. Fee:
Plumb. lop. Fee:
Elcc. Insp. Fec:
NOTE: This ertinmte does not include jeer slue m other Departments (i.e. Planning, Public Works, Fire, Sunimry Server District, Schaal
District, etc.). These fees are hared on the prelintinarr information arailahle and are only (tit ectinmte Contact the Dept for aaldn'I info.
FEE ITEMS (Fee Resolution ll -053 Elf. 7/171 U
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$134.00
Mechanical
IBAPPEOT Other Appliance/Equip
Suppl. PC Fee: Q Reg. O OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:.
$0.00
Suppl. Insp. Fee,0 Reg. O OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
Construction Tax:
Administrative Fee: IADMIN
$42.00
O
E)
Work Without Pennit? O Yes (j) -No
$0.00
Advanced Planning, Fee:
$0.00
Select a Non -Residential
Building or Structure
O
A
Travel Documentation Fee: ITRAVDOC
$45.00
Strong, Motion Fee: IBSE1SMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee. IBCBSC
$1.00
SUBTOTALS:
$133.50
$134.001
TOTAL FEE:
$267.50
Revised: 07/01/2012
CUP ERTINO
OWNIER-BUILDER DISCLOSURE EORM
C01+41:4UIJITr' DEVELOPMEPdT DEPk Tt iEI�!T • 31JILD!NO DIVISIGN
10300 TORRE AVENUE • CUPERTINO, C.4 °5015-3255
(408) 777-3228 • FAX (408) 777-3333 • �uiisin�i��u�a i�do�❑
Dear Property Owner(s):
An application for a building permit has been submitted in -your name listing yourself as the builder -of the property
improvements specified at:
SITEADD S
�O/ APN / 1O� aP4
7
e
O
OWNER NAIVE
I N OV+a�ER ADDRF S
�11i
DESCRIPTION OF WORK:iU
'
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.)
511. 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.
312. 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.
5-6_( 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.
5)f4. I understand Contractors are required by to be licensed and bonded in California and to list. their license
CCnum//////''bers on permits and contracts.
W5. I understand if I employ or otherwise engage any persons other than California licensed, Contractors, "and the
otal value of.my construction is at least five hundred dollars ($500) including labor and matenals I maybe
considered an employer under state and federal lav✓
s
6 I undd`rstand if I am considered an ' employer under state and federal aaw I must register wdh the state and
F federatgovemment,withhold payroll taxes, provide workersjcompensabon;dlissabllltymsurance and contrlbute to
r.qunemploymentcpmpensation for each employee , I also understand my failure to abide by these laws maysublect, _ <
�- ' ;-cam, me'to'senous:finanaal risk -- — -- -- — k �"'Y;' • ""' - _ _ _ _ ._,
�7 I understand under California Contractors' State Lic nse'Law an Oyner Builder vrho builos single family
residential s+rucfures cannot legally build them v✓ith the intent to o er nem for sale,' bnless all xvork isperformed by
licensed subcontracior and the nurnberof structures does not exceed rout v,!thin-any"calendar year,br all of the work
is periormed under contract with a licensed general building Contractor.
8.-1 understand as an Owner -Builder if I sell the propariy for v✓hich this permit is issued, I may be held liable for
'-'any�financialror.pers5nal injuries sustained by any subsequentov✓ner(s) that result from any latent construction
detects in the workmanship or materials.
- T�tiv0++merBuilderFan1.101 doc revised O4/lQ/!0
tS'i- T, r U-1.1'.
W-9. 1 understand I may obtain more information regarding my obligations as an "amoloyer' 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.cslb.ca.gov for more information about licensed
contractors.
s v 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.
1. 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.
*S -4V-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 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.
I her
(Sec
Lend
15
:TIONS: Please complete the following construction lending agency information.)
y.affirm that there is a construction lending agency for the performance of the work for which this permit is issued
97 Civ.)
Name: Lender Address:
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 acceptabre to the city may be required to be presented ivlien the permit is issued . .
the property owner's si nature.
(Owner's Signature: . Date:
The: following'Authorizatior Form is required to be completed by the property owner only when designating an
the grope ty owner to apply for a' censttiction permit for the Ov✓ne'r-Builder).
AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF
Notice to Property, Owner, the execution of which I,undemtand is my personal' responsibility, I hereby
`ollowing person(s) to act as.my:agent(s) to apply for, sign, and file the documents necessary to obtain an,
Permit for my project.
>truction Project (or Description of, Work):
or Address:
to the city maybe
Owner's Signature:
t ,
s
v owner•for the adds
to be presented
Date:
NwerBuilderForm 1010.doc revised 04/14/]O,:y- -:
CONSTRUCTION PERMIT ,APPLICATION
I COiviiaUPa i :' D� JcLCPi:ici7T DE?.'.?TirL=i•;T • cUli i•i:dG ul'•.'Ig!O'^:
10300 TOR = E AMENUE ' CUMEDTI?!O, CA. SE0 i-'.-3250
CUPERTIN4 (408) 777-3228 • FAX (408) 777-3333 ' buildi�e(rJccG�riiro.DrO
❑ CONSTRUCTION ❑ ADDITION ALTERATION / Tl ❑ REVISION / Da- RRZD 9
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