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13030162CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR CONTRACTOR: 20800 VALLEY GREEN PERMIT NO: 13030162 DR OWNER'S NAME: 20800 VALLEY GREEN DR PO BOX 1368 DATE ISSUED: 03/28/2013 OWNER'S PHONE: 4082530200 CARLSBAD, CA 92018 PHONE NO: 0 License LICENSED CONTRACTOR'S DECLARATION Lic. # 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. 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. 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 laws relating 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, 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 Municipal Code, Section 9.18. Signature Date 50 / OWNER - BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business& Professions Code). I hereby 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 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 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 forthwith comply with such provisions or this permit shall be deemed revoked. 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 laws relating 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, 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 -p source regulations per th Cupertino Municipal Code, Section 9.18. „ Signa Date JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL * *UNIT 439* *INSTALL (N) ELECTRICAL WASHER & DRYER HOOKUPS. NEW PLUMBING, MECHANICAL & ELECTRICAL Sq. Ft Floor Area: I Valuation: $500 APN Number: 32609040.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 PERMIT ISSUANCE OR D +RO T CALLED INSPECTION. Issued by: Date 7 RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9:12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sec ti 255059 25533, a 25534. Owner or authorized ag t: Date: 2�f'� CONSTRUCTION LENDING AGENCY I hereby affirm 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional /V k CONSTRUCTION PERMIT APP, ICATION CONIIN-IUN I TY DFIELOPI'vil-EN'T DEE_P:`IRTMENT - -_EU!_!_F.`N.GG D IV! S!ON 03Q0 TO RREAVENUE -CUP EFIMINO, CA C-c-O I A -3255 c UP N (408) 777-3228 • FAX (408) 777-3333 • F] NEW CONS , R T T(-rMN F-1 A nnrrTrW F-1 F-I PROJECT ADDRE . Sr aireeo��__A" APIN 3,z& 0 OWNER NAME Zo 19,bo 0 P HO 0a STREET ADDRESS 110ENSE T ypti FAX CONTACT NAME <1 C-)aA74 E-MAIL .. 0"AE 14r) E-MAIL STREET ADDRESS CITY TE, flAiu PHONE - cl li�r_ g(OWNER ❑ OWNER-BUffDBR ❑ OWNERAGENT ❑ CONTRACTOR. ❑ coNTRAcTopAGENT El. AR=cT El ENGNEER ❑ DEVELOPER ❑ TENANT I CONTRACTORNAIAE- PROPOSED .PFOSLEE 4qONSIR. TYPE 4STORIES -2 110ENSE T ypti Bus. Lic # COlaANY31b., njV_ A MOO WJ E-MAIL .poxaff"'m FAX STREET ADDRESS MY, SMM, ZIP Ll L4 0( flAiu PHONE - cl li�r_ ARCHMMENGU,MERNAME LICENSENUMER below, I certify tq each of the following.. I am the property owner or aw 9 BUS. LIC # COMPANYNAME 6E-NMfAlL" FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK ocal es- . EC=GUSE PROPOSED .PFOSLEE 4qONSIR. TYPE 4STORIES .MaSTG AREA AREA, DEMO TOTAL [AREA. NE . rAREA BATEROOM REMODELAREA. OTHER [REMODEL MEA .poxaff"'m DEMAREA_ DETACH ❑ ATTACH ncomb srow .0140'. AD=OM­ ❑ No ,Ml*PLl(2Anox ?Lwwr"kpm,y 1F MPROVIDE COPYOi'.: []'NO m-Q0WGAuR0vALuTrim By.m y signature below, I certify tq each of the following.. I am the property owner or aw 9 ocal es- CITY OF CUPERTINO .M FFF, ESTIMATOR — RITII,DING DIVISION '1tec:h. Plan Check- F L1aeh. Permit Fee: Other ,tlech. Insp. ilech. Insp. Fee: Plumb. Plan Check Plumb. Permit Fee: Other Plumb Insp. Plumb. Insp. Fee: Elec..Plan (. heck Elec. Permit Fee: Other Elec. Insp. Elee. Insp. Flee: NOTE: This estimate does not tinclude fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These ees are based on the prefindna information available and are only an estimate. Contact the Dept-for addn'l info, 20800 VALLEY GREEN DR # 439 DATE: 03/28/2013 REVIEWED BY: MELISSA JimADDRESS: APN: 326 09 040 BP #: `VALUATION: $500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: 0.0 PENTAMATION PERMIT TYPE. WORK " *UNIT 439* *" INS TALL N WAHER & DRYER HOOK UPS. NEW PLUMBING MECHANICAL & SCOPE ELECTRICAL '1tec:h. Plan Check- F L1aeh. Permit Fee: Other ,tlech. Insp. ilech. Insp. Fee: Plumb. Plan Check Plumb. Permit Fee: Other Plumb Insp. Plumb. Insp. Fee: Elec..Plan (. heck Elec. Permit Fee: Other Elec. Insp. Elee. Insp. Flee: NOTE: This estimate does not tinclude fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These ees are based on the prefindna information available and are only an estimate. Contact the Dept-for addn'l info, FEE ITEMS (Fee Resolution 11 -053 Eff. 711112,/ FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (E) Reg.: 0. OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ® Yes (D No $0.00 Suppl. Insp. Fee-.0 Reg. Q OT F-01 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: E) Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure E) i Travel Documentation Fees. Strong Motion Fee: 1BSEISMICR $0.50 2.0 hrs $266.00 Inspections ISTINSP Inspection, Hourly Bldg Stds Commission Fee: 1BCBSC $1.00 $1.50 $266.00 ® $267.50 Revised: 01/01/2013 IR N-o 1- MNER_BU[- DER MIS-1GLOSURE 1=ORNA CDMMUNITY DEVE LOPi� [,ENT DEP.` -•1-F1, i M -N i ° BUILDING DIVISION 10300 TORR- AVENUE - CU'PERTINO, C„ 95014-32055 (408) 777 -3228 FAX (408) 777 -3333 buii�ina� o= �nao-a 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: ` SITE ADDRESS APN ©� I SP4 OWNER NAME R ` OWNER ADDRES C, � 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 officlaf 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 VERiFI.CATION OF INFORMATION . (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 5 � 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 persdriaily. I, as an Owner - Builder, maybe 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-L. 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. S3. 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.fled in his or her name instead of my own. (L4. 1 understand Contractors are required by to be licensed and bonded in California and to list their license numbers on permits and contracts. r5L5. 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" ynder state and federal law. s V 6.1 understand ►f Cam cons.;I -d`an `e iployer Understate and federal Iaw;,i must reg[sferwith the state and federal government, withhold payroll faxes, provide v.rorkers'`compensation' disability insurance, and contn6ufe to - - unemployment compensai�on for each; °employee- l -also understand my failure to''abitle by these laws rnay`subject - _ - �7. I understand. under California Contractors' State License Law, an Owner.Builder:who 6uildsstngle- family residential structures cannot legally build them with the intent to offer Them for sales unless all work is performed by - -_.: - - -- - -- licensed subcontractors andthe number of structures does not exceed tout vVithin any calendar year, or all of the work l 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 arty financial or person- al';injuries sustained by any subsequent owner(s) that result from any latent construction I defects in the,workmanship ormaterials r.- OidrrerBuilderForm_2010.docrevised 0 4114110: 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 I icense Board (CSLB) at 1- 800 - 321 -CSLB (2752) or www.csib.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. 7 �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. V 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. WNSTRUCTION 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, foriim.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 si nature. Prgperty Owner's Signature: � Date: -------------- - - - - -- - -- ------- - - - -'----------------- -- ------ - - - - -- ----- - - - - -- -- - - - --------- - -- ---------- - - - - -- - (NOTE.!,. The following Authorization Form is iequl ed to be completed by the property owner only when designating an aggnt of the property owner to apply for a' construction permit for the Owner - Builder). A i ITun017ATIMI nG AI.PKIT Tn Ar--T nM PRnPPIRTY nVE NFR'S BEHALF I deb are under pe alb above: informaftoh and verification acceptable signature. lent per}ury that l airs the property owner for the address listed above and 1 p°rsoriaity filled out thy` i#�fyts'aceuracy Note: Acopy of the property owner's driver's license, form notarization, or other the city may be required to be presented when the permit is issued to verify the property owner's Date: OwneBudderFonn 2010.doc revised 04 /14/10 CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408- 777 -3228 Fax: 408-777-3333 JOB. ADDRESS: e ge, Atl 1 PERMIT # c3v 3 61 6 2 OWNER'S NAME: v 1 7 PHONE # Dfi o2 GENERAL CONTRACTOR: BUSINESS. LICENA # ADDRESS: i`S ziy 13md CITY /ZIPCODE: < *Our municipal code requires all businesses working in the city to have a City of Cupefrtino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: -2, — Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing - Septic Tank Sheet Metal Sheet Rock Tile -2, — Date