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12090123 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20990 VALLEY GREEN DR CONTRACTOR:KORET FOUNDATION PERMIT NO: 12090123 OWNER'S NAINIE: KORET FOUNDATION 1050 RALSTON RD DA'Z'E ISSUED:09/132012 OWNER'S PlIONE: 4082530200 BELMONT,CA 94002-2243 111IONE NO: V LICENSED CONTRACTOR'S DECLARATION •1011 DESCRIPTION: RESIDENTIAL COM\IFRCIAL CI License Class Lie.q APT 605- INSTALL WASHER AND DRYER HOOK UPS Contractor Date I hereby uflirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full farce and effect. hereby affirm under penalty of perjury one 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 die performance of the work forwhich this APN Number:32609053.00 Occupancy Type: permit is issued. .API'LIC,\Yf CF.R'1'IRICATION I certify that I have read this application mid state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances mid state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY F M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of diis permit. Additionally,the applicant understands and will comply, Issued b)': /7i with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to my roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for 1 inspection. "J✓✓�'f✓Vt// ON'MSR-RI111.DQ:R DECLARATION Signature of Applicant: Date: hereby affirm that I am exempt from the Contractor's License Law for ane of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BE 1-I'ER I,as owner of the property,or my ernployces with wages as their sole compensation, will do the work,aid the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to IL\"LARDOUS MATERIAI S DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&Safety Code,Sections 2.5505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Ilealth&Safety Code,Section 25532(a)should I store or handle hazardous 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for whichthis permit is issued will maintain compliance with the Cupertino, umcip Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safer Code,Secti ys 25505,25533,a 5534. Section 3700 of the Labor Code,for die perfomtance,of die work for which this9 Ow_nrr or authorized agen )ale: permit is issued. I certify that in the performance of the work for which this Permit is issued,I shall not employ my person in my manner so as to become subject to the Worker's Compensation laws of California. If,after making this cenificate of exenhption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensa ion provisions of the Labor Code,1 must I hereby affirm thin there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANI'CERTIFICATION Lender's Address I certify thin I have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relatng to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCII TTEC"f'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per th Cupertino Municipal Code,Section Licensed Professional 9.18. Signmur Date r CONSTRUCTIONI PERMIT APPLICATION COivilaUr;l D�!ELOFFa_P1T DEP: Tie!--:•:T • BUILDNG DI'diSEON 10300 TOrtR=rt/=:.TUE • CU?=oTCiO, C,'.S�Gi-''.-325C \� •i, I CUpERTINO (ZC-8)777-3228 • =AX('08)777-3333 •ouildincoceeertiro.oro El tvn" Ir—i ' W CONSTRUCTION ❑ ADDRION ❑ ALTERATION/TI u REVISIO`i/DEi--R-2= ORIGLY.IL P&_W, -1 r7- Cr ADDRES" _ e_ Cee� .f�c• #�� 5 I APNq 3,Z 6 49 0 5 4 ME 2�6/ O PHO- EalAn. f AD MS CrrY iATE,ZP Fqxe_ r. r�r2 e2yCT N PHO E-MAn. SrREET ADD S AIS ylP FAX' o'wrmc ❑ OWrm'B=ER ❑ owtmtA= ❑ CONTRACTOR ❑COx CTOR AGENT ❑ AR=CT ❑m;axEm ❑ DEVELOPER ❑mt,vrr CONTRACTORNA.ME' LICENSE NfIMHER, 'LImVSE TYPE .- - HUS.LICq� . CObffANYN E-M � FAX STRFT ADDRE $_ .STA ZIP PHONE ,K ARCHITEC7/ENGD4MNAME LICENSE NU ®ER BUS.LIC q COMPANYNAME __. ._.. ... Eh111L FAX •. STREET ADDRESS C=.STATE,ZIP PHONE DESCRIPTION OF WORK ' l Lhoo 640 EVSIDIGUSE - FW:P.O.SIDISE CONSTR.TYr> asroRns �-•` HFlo T ... i . . - -'I ..'-IYP _.g ..oma '•'Rr`� 7a 6H:Ttl DOSI'O C FLOOR DEMO TOTAL 1 ;t;�,�� M ARFa AREA AREA NETAREA ?';yY.�y HA1mOOM _ IOTQIDS_ OIFffR 54- IrM '�y.l� �'y�,"�_ F' ' REMODEL AREA REMODEL AREA RPMODEL ARBA _ ! +C+ y wrt - PORCHAREA DECKAREA TOT--. E- tPORCHAREA, GARAGE FREA:'❑ OETAQT .� .R�"S ( °'I=3 � .- �_ 'w .......... ' ' ❑ ATTACH `- C =C -c+•a ,. rOwru.wnmms iswumta mvr' .;pva.. sHcocm sroav piv r �� - ..,, .:-'=.; ,� vxswrer.cnnox. ❑ ies .exE.t.Pxnvroz coPr¢,' . euwrtR'sxAMt. ',+• "` ;` �,-�" By my signature below I arhfy to each of the following I am the property owner or authorized agent to act on the property�uwOers behalf I have ad thss y'� ., .� applicafion and the mfoiIDSDon I have provided is,cotrecL I hav a read the D npdon of Work zndiverify rt is accurate I agree io comply with el]applicable localrt r -.� t Ordinances and state laws mlanng[o buil corutrucoon I authanze re ntadves of Cupertno to enttr the above idennficd propetry tar aupecnon ses t' - � . PmPO t t t 'i*�t.. "` 'SUPPLIlKII•ITAL ATFOIL�L4TION REQUIRID > . --� _ - .�_ _- � � �-5-:° `�'4-` . r n� New SFD or Mtil[ifam17y dwellings Apply for dcmohhon Delm[t for --' - •_ - - w exLstm bu�ildm s ' I emoLhon er�,nit rs re ��.._-,�- •co "`cER� e ���„� +e � '�- n g_ g() P gntred prior to.issiance of budding - T,�- .f a. z—.. ;r ' pemut for new bnlldlligl P"r`�f�- e tea,:.';' +,-��+..�;• s' - t �.XPx _L � _ t�S �P{N: -.'''�' 2.. Commema]Bldgs Provide a comple ed Hazardous Mat=na]s Dlsdosar- 'sLi."'a .+� _ _ � ' Iorm if any Hazardous Materials a.:b trig used'2s part of:tiis project' e� .:�,s � F _~ �'.?� ` �_, i8 : -. '. Copy ofPlanamg,Approval Luer or Meeting with P1aDDiagp;ior ro ��."��'� ;- ,,,: �" �� a '_ ' . -sobml'ta7 of Btuldin�Permlt abpheihon. nt+.iOx r .cvzra'RE,sE�r. A t " ..may,-• _ -h y+;,_ dy . . r BId PP 2011 dec re ued 03116111- q 3116/11 F rT � ✓'�� it $F 3. . 01AINER-BUILDER DISCLOSURE FORM COMIAUN'ITf Dc/D OP!:4EN'T DEP4R MIEN I • BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255 - (4,8)777-3223- F?X (403)777-3333 • S�iidin�i,.c_�arioc.o,-a CUPERTMO Dear Property Owner(s): An application for a building permit has been submitted in yodr name listing yourself as the builder of the property improvements specified at: SrrEz DRS S .vPN ©� BPm OWNER NAMEET V �N' *t d OWNER ADDRESSLtLE , DESCRIPTION OF WORK: P P 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 ., (DIRECT ONS:Please read and initial each statement below to signify you understand or verify this information.) � 1. 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 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. 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 (esponsibility. 5JL3. I understand as an "Owner-Builder" I am the responsible party,of record on the permit.,l 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 instea'd'of my own. ' 4. 1 understand Contractors are required by to be licensed ar d Bonded in California and to list their license numbers on permits and contracts. 5L5. I understand if I employ or otherwise engage any persons, other than California licensed,Contractors;and the j 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 federatlaw �j U 6 I'iinder�tand rf I am co sldered an 'employer" under state and federal law I m asthreglster wdh thestateand ? . federal government iivithhold payroll taxes, provide workers compensatio dlsabTlity';i suyance�and contribute to < • ' ' une'rfiployment c pensaUon for each-employ � 1 also understand my failure to abide by�these laws may subject-=•-:_ •,�_,r, n' 7: I understand under California Contractors' State License Law an°Owner Builder who builds single family residential structures cannot legally build Them with the intent to over hem for sale unless a//v ork is pertormed by - - icensed subcontractors and the number of stfuctures does not- eed fourVeithin in-any year,'or'all'of the work is performed under contract with a licensedgeneral building Contractor. 8'I understand as an Ovmer-Builder if I sell the property for which this perrmit is issued, I may beheld liable for zy Pnancial'or personal.injuries sustained by any subsequent [fiat resultfrom any latent construction an defects In the workmanshi or materials. Nty+_ x `c. • e a - ' p t°"+�"x �'OlimerBvrlderForm 1010 doc}e�ised Os/Ia/10- s , . :ii.^3-i.� -: -. ' ' �:�. _ ._N.}:l_..i._3'n 'L''.G�y..�.r•1 t-+ �F .... �� i.:. :�'. S�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 wvw.cslb.ca.gov for more information about licensed contractors. _:�10. I 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. :5J1 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 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 :emplbyee of that individual or firm is injured while working on your property, you may b'e 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 he reby.afnrm 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 property owner's drivers license, form notarization, orother verification acceptable to the city ay be required to be presented when the permit is issued to vent the property owner's signature. Property Owner's Signature: Date: 9/) •/� (NOTE:'•The following'Authorizatiori Form is requited to be bompleted by the property owner only when designating an ' `,_'agent of th'e properly owner to apply for a"oonstm ction permit for the Owner-Builder). d'v . AUTHORIZATION OF AGENT TO ACT.ON PROPERTY OWNER'S BEHALF ,' + ,�"F�ccludrng;the Notice to Property.Ota=ner, the execution of which 1•understand is my personal responsibility, I hereby ._.. atittionze-the following person(s)to act as mr' a9ent sO to aPPIY for, sign, and file.the documents necessary to obtain an .. t;Owner,=Builder Permit for my project. .: •. . .. of;Cohstrtiption Prefect(or Description of Work): ProleetLoca4onorAddress I ra NameofAuthonzedAgeFnt* r ,vF + 2 ;,r Tel No �� .€�-'{SyT3�,�'r'�'1f«tiytu4.��7•�"•�"h-F �t ���•t , Rn.. S�r" "e -t'LV n t � r a.+. 5t�"i {t .V' �`i z'u+ .x" rAddress of Authorized Agent i v: `. ''is �`m '" i . Frideclare under penalty of perlury-tthat I am,the property owner.fo�the address listed atiove and Lpersonally 511ed out the - above information and cerhry its_accuracy=No+e.:A_°dopyof the'p{ope } ov ers drivers tfcense' fdrm notanz'atlon or f`vemrdafio 'acceptable to the city maybe required to be presented when the permit Is issued to verify tfie property owner's • = �' ' —signature. Property Owner's Signature: Date: OiarerBuildw-Form 2010 doc retised 04/14%10•-'t-1 `-— -4`t -