13020074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 13020074
DR
OWNER'S NAME: 20800 VALLEY GREEN DR PO BOX 1368 DATE ISSUED:02/13/2013
OWNER'S PHONE: 4082530200 CARLSBAD,CA 92018 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.q **UNIT 426***NEW WASHER&DRYER HOOK UPS.NEW
PLUMBING,MECHANICAL&ELECTRICAL
Contractor - Date
I hereby affirm 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 force and effect.
I 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 the performance of the work for which this APN Number:32609040.00 Occupancy Type;
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct I agree to comply with all city and county ordinances and 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 DA 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 Date: Z 1
granting of this permit. Additionally,the applicant understands and will comply c
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 any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1;as owner of the property,aexclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
m
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,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: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I 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,m provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
perfommance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5505,25533,and 34.
Section 3700 of the Labor Code,for the performance of the work for which this ?
Owner or authorized agent: � 7i�i ate:
permit is issued.
I certify thavin 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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the perfommance 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
APPLICANT CERTIFICATION Lender's Address
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 laws relating
to building concoction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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 plicant understands and will comply
with all non-point source regulations per a Cupertino Municipal Code,Section Licensed Professional
9.18.
Signa re ti � Date
-
i CONSTRUCTION PERMIT APPLICATION
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COMN-4UNIT(DE`IELOFPdcNT Dc=1RT11.4_piT• =U!'tDiNG DI'•:'';S;O?i
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0300 TORRE AVENUE • CUPERT!?10, CA 95014-3255 'to
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❑Y.w CONSTRUCTIoN ❑ ADDITION \El ALT,-KkT10-.,ri/1/I/��/./�❑ REVISION/DMIEILR/EED�C/� ORTQD4AL PFaRNffr'
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OWNER 0 ovmt-HUn.DER ❑ OwmmAGENT 0 cONmAcroR OcONmACrOR AGSM 0 ARCJSf 0 mmm 0 D, Y oPER Orm;A
CONTRACTORNAME' - UCENSENUMEER: - LICENSETYPE
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COMPANYNAME E-MEE,t. -. .•.
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DFSCR@TION OF WORK
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AREA AREA AREA NEPAREA
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By my sigoanne below,I ontify to each ofthefollowmg I maths grope ry ovmeror agmtm ac e p ope ty owvcfs behalf I7}ave read flus '
application and the mt`oraosaonIhavep{o ded>F,coaecL I have Lead the D tion of Wort and verily it rs accamte I agree to comply with all applicable Iota!
ordinances and state laws relating m b coashuctio I authorm es of CllperNio to emer the abovo-rdmt£ted propeRyfor mspech9n proposes
STgnatvre ofA hcmU <<'' "" > w 4a .* l ,; ` .-+,.,.
- SUPyPLEMENTAL)�RMAT1
-NewSFD orMi>ZhfamT7y dwe]1m� Apg. emolatton pemTrtfor ` �i 1 ��
existmgbw7dmg(s).`DemohhonpermrttsPeyGuedpnottoassamceotbwldmg
permit fornew bnfldiag
Commercial Bldgs Pmvade a`6ompleted Iiaim'doas Materials Disclosure
form ifabyFIazadOUs Materials-are beluga'sed'ffipaii.6hhs,pioject`:...-:
—Copy of Planning Approval Letter orldeeting with Plau*gprior to
Submittal of Building Permit application. -
B144,pp IOl Ldoc revised 03/16/11
CITY OF CUPERTINO
IraFEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20800 VALLEY GREEN DR#426 1 DATE: 02/13/2013 REVIEWED BY: MELISSA
APN: 326 09 040 BP#: *VALUATION: $500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY Multi-Famil Dwellin Buildino is PENTAMATION 1RMAP1
USE: Y 9 >3 Stories 0 Yes 0 No I PERMIT TYPE,
WORK INSTALL N WAHER & DRYER HOOK UPS. NEW PLUMBING MECHANICAL& ELECTRICAL
SCOPE
APPLIANCE/EQUIP TYPEFEE ID QTY UNITS BP FEES
Other Appliance/Equip 113APPLOT 2 # $134
TOTALS: $134.00
;I'iy rc
Mech.Plan Check 0.0 hrs $0.00 111uurb, Flat(':Poe'ek (Stec. Plan C ed
Mech.Permit Fee: IMPERMIT Phtrnh Pei mil Pee: e(..Penni!lot:
Other Mech.Insp. 1 0.0 hrs $45.00 Ocher Plumb Inmy;, Otho 1,1,i.Insp.
;birch.ht}Z;.I Phwrb.hmp.Feer Ffec Lr.p. 1-'ee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc.). These ees are based on the rmina estimate. Contact the Dept or addn'[info.agnrmaaa
FEE ITEMS (Fee Resolution 11-053 EfE 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Cheek Fee:
SuppL PC Fee
PME Plan Check: $0.00
Permit Fee:
SuppL Insp Faa
PME Unit Fee: $134.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: ]ADMIN $42.00
Work Without Permit? 0 Yes G No $0.00
.Advanced Planning,Fees:
Travel Documentation Fee: 1TRAVDOC $45.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: ]BCBSC $1.00
ff $2
_ 67.5
\� �. Revised: 01/01/2013
I
OWNER-BUILDER ILDER D€BGi OSUR_ FOR€tl
COMMUNITY DEVELOPMENT DER='.RTN=NT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CU PERTI Pd 0 (408)7773228• FAx(408)777-3333 • 5uiidirF3.�u�a:�o.o-�
Dear Property Owner(s):
An application for a building permit has been submitted in your hams listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS h 1., APN j BP$
e
OWNER NAME ' [' OWNER ADDRESS
J f / °7
DESCRIPTION OF WORK: e4, .t e- x �
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
(DIRECTIONS.,Please read and initial each statement below to signify you understand or verify this information.)
S1. 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.
5�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.
(,/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.
4.I understand Contractors are required bylaw to be licensed and Bonded in California and to list their license
numbers on permits and contracts.
ciilb. 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 may be
considered an "employer,uhclerstatd and federal law.
1 understand if I am considered an."employer"under state and federal faw I must reglsteL with the state and
federal government;,vnthholct payroll taxes provlde workerscompensato`n,,dlsabilityinsurance :and contributeto
unemployment cdmpensationfor each employee l also understand my failure to abide by these laws may'sub)ect
me toserious financial`nsk: -- ''
- e o. .
S U 7. 1 understand under California Contractors'State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the Intent to offer them for sale, unless all work is performed by
licensed subconfracfors and tfie number of structure's does not exceed fourwithfri any calendar year, or all of the work 1
is performed under contract with a licensed general building Contractor.
�/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 financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects.in the workmanship or materials, .
OwnerBuilderFom 2010.doe revised 04114110'
-.. (3D
,.
ilh. 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.cslb.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.
j�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.
5
/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
th
, ose Contractors are properly licensed and the status of their workers'compensation insurance coverage.
C04STRUCTION 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: 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 vgdficatlon acceptable to the city may be quired to be presented when the permit is issued
to Verify the property owner's sf nature.
Property Owner's Signature: Date:----------------------------
��/�^/_3
-- ---------------------' -=------- -- '------------ --
(NOTE'The following Authorization Form is required to be completed by the property owner only when designating an
age•;nf of the properly owner to apply for a'con$truction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF
arluding,the Notice to Property Owner, the execution of which 1,understand is my personal responsibility, I hereby
authorize the following persons)to act as.my`agent(s)to apply for, sign, and file the documents necessary to obtain an
Ovrher Builder Permit for my project.
Scope of,Construction Project(or Description of Work):
4
a Pro)ectLocation or Address: ) _
2 Name of Aufhonzed Agerif r +;".;t °' t u, Tel No -
Address of Authonzed'A'gent i .•i"
hfeclare under penalty of perjury_that I arrr the property ownerfor the address listed above and I personally filled out the
above Information and:certlfy 1fs.accuracy,;Nofe:Acopy ofthe property owners dnver_'s license, form notarization or other..,.::
ve"rification acceptable fo the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
'' i - CinweiBuilderFomi 2010.docrevised04/14110