11100115CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20875 VALLEY GREEN DR CONTRACTOR: KORET FOUNDATION
OWNER'S NAME: KORET FOUNDATION
`WNER'S PHONE: 4082530200
I LICENSED CONTRACTOR'S DECLARATION
License Class 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
i f/ OWNER -BUILDER DECLARATION
20875 VALLEY GREEN DR
CUPERTINO, CA 95014
JOB DESCRIPTION: RESIDENTIAL
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). S v
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,
-)sts, and expenses which may accrue against said City in consequence of the
anting 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 '
PERMIT NO: 11100115
DATE ISSUED: 10/18/2011
PHONE NO:
APT 7- INSTALL WASHER/DRYER HOOK UP
Sq. Ft Floor Area: I Valuation: $500
APN Number: 32609064.00 I Occupancy Type: I
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by �1---Bate:
'
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, Sections 25505, 25533, nd 25534.
Owner or authorized agent:? Dater
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
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - build inwalcupertino.org
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 Clef !t ��,� ��
APN ` `Z
BP#
OWNER NAME // -?�
Go %'r°-� 13CC
OWNER ADDRES e
( I'
DESCRIPTION OF WO K:
/ w
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.)
�11. 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.
J' / 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.
5_2Z_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.
5. 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' under state and federal law.
L6. 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 contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
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 subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
5/8. 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.
Oia,ne7Builde7-For•m 2010.doc revised 04114110
6 ITEMS OF 12
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32609064.00
DATE ISSUED.......: 10/18/2011
RECEIPT #......... BS000015069
REFERENCE ID # ...: 11100115
SITE ADDRESS 20875 VALLEY GREEN DR
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER KORET FOUNDATION
ADDRESS 20875 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM VILLAGES AT CUPERTI
CONTRACTOR .......: LIC # *OWNER*
COMPANY KORET FOUNDATION
ADDRESS ..........: 20875 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE .........
OPERATOR: SylviaM
COPY # : 1
FEE ID
UNIT
QUANTITY
AMOUNT PD
-------
-TO -DT
THIS REC
NEW BAL
1BCBSC
VALUATION
--------------------
500.00
1.00
0.00
1.00
0.00
1BREMRECEP
NO. OUTLETS
1.00
44.00
0.00
44.00
0.00
1BSEISMICR
VALUATION
500.00
0.50
0.00
0.50
0.00
1PREPPIPE
FLAT RATE
1.00
44.00
0.00
44.00
0.00
1STINSP
UNITS
1.00
130.00
0.00
130.00
0.00
1TRAVDOC
FLAT RATE
1.00
44.00
----------
0.00
-----44_00
-- ---
TOTAL PERMIT
----------
263.50
0.00
263.50
0.00
METHOD OF
PAYMENT
AMOUNT
REFERENCE
-------------
NUMBER
-----------------
CHECK
---------------
---------------
527.00
2116/2117
TOTAL RECEIPT
527.00
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
ism
CUPEFtT3N4
(408) 777-3228 • FAX (408) 77 -3333 • buildina(cDcuDertino.org 11
`i l vUI
❑ NEW CONSTRUCTION ❑ ADDITION ALTER�AjTION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT R
PROTECT ADDRES. ® ��.�-T W APN # L3 -7
OWNERNANIE PHO o E-MAIL
STREET ADDRESS / ` } CITY, STATE, ZIP FAX
r
NAME PHONEDDRESS CITY, STATE, ZIP FAX
EXISTINGUSE I PROPOSED LEE i CONSTR. TYPE I # STORIES
BldgApp_2011.doc revised 03/16/11
❑ OWNER ❑ OWNER -BUILDER OWNERAGENT ❑ CONTRACTOR ❑ CONTRACIORAGENT ❑ ARa=CT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME;/
LICENSE ER
LICENSE TYPE
BUS. LIC #
77 �_
U
COMP ANY NAME
E-MAIL
FAX
STREET ADDRES
STATE, ZIP
PHONE
ARCHTTECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANYNAME
E-MAIL
FAX
?
(
STREET ADDRESS
CITY, STATE, ZIP
PHQIE�
?SCRIPTION OF WORK / Y)'
EXISTINGUSE I PROPOSED LEE i CONSTR. TYPE I # STORIES
BldgApp_2011.doc revised 03/16/11
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20875 VALLEY GREEN DR CONTRACTOR: KORET FOUNDATION
OWNER'S NAME: KORET FOUNDATION
`WNER'S PHONE: 4082530200
I LICENSED CONTRACTOR'S DECLARATION
License Class 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
i f/ OWNER -BUILDER DECLARATION
20875 VALLEY GREEN DR
CUPERTINO, CA 95014
JOB DESCRIPTION: RESIDENTIAL
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). S v
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,
-)sts, and expenses which may accrue against said City in consequence of the
anting 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 '
PERMIT NO: 11100115
DATE ISSUED: 10/18/2011
PHONE NO:
APT 7- INSTALL WASHER/DRYER HOOK UP
Sq. Ft Floor Area: I Valuation: $500
APN Number: 32609064.00 I Occupancy Type: I
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by �1---Bate:
'
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, Sections 25505, 25533, nd 25534.
Owner or authorized agent:? Dater
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
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - build inwalcupertino.org
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 Clef !t ��,� ��
APN ` `Z
BP#
OWNER NAME // -?�
Go %'r°-� 13CC
OWNER ADDRES e
( I'
DESCRIPTION OF WO K:
/ w
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.)
�11. 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.
J' / 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.
5_2Z_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.
5. 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' under state and federal law.
L6. 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 contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
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 subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
5/8. 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.
Oia,ne7Builde7-For•m 2010.doc revised 04114110
6 ITEMS OF 12
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32609064.00
DATE ISSUED.......: 10/18/2011
RECEIPT #......... BS000015069
REFERENCE ID # ...: 11100115
SITE ADDRESS 20875 VALLEY GREEN DR
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER KORET FOUNDATION
ADDRESS 20875 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM VILLAGES AT CUPERTI
CONTRACTOR .......: LIC # *OWNER*
COMPANY KORET FOUNDATION
ADDRESS ..........: 20875 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE .........
OPERATOR: SylviaM
COPY # : 1
FEE ID
UNIT
QUANTITY
AMOUNT PD
-------
-TO -DT
THIS REC
NEW BAL
1BCBSC
VALUATION
--------------------
500.00
1.00
0.00
1.00
0.00
1BREMRECEP
NO. OUTLETS
1.00
44.00
0.00
44.00
0.00
1BSEISMICR
VALUATION
500.00
0.50
0.00
0.50
0.00
1PREPPIPE
FLAT RATE
1.00
44.00
0.00
44.00
0.00
1STINSP
UNITS
1.00
130.00
0.00
130.00
0.00
1TRAVDOC
FLAT RATE
1.00
44.00
----------
0.00
-----44_00
-- ---
TOTAL PERMIT
----------
263.50
0.00
263.50
0.00
METHOD OF
PAYMENT
AMOUNT
REFERENCE
-------------
NUMBER
-----------------
CHECK
---------------
---------------
527.00
2116/2117
TOTAL RECEIPT
527.00
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
ism
CUPEFtT3N4
(408) 777-3228 • FAX (408) 77 -3333 • buildina(cDcuDertino.org 11
`i l vUI
❑ NEW CONSTRUCTION ❑ ADDITION ALTER�AjTION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT R
PROTECT ADDRES. ® ��.�-T W APN # L3 -7
OWNERNANIE PHO o E-MAIL
STREET ADDRESS / ` } CITY, STATE, ZIP FAX
r
NAME PHONEDDRESS CITY, STATE, ZIP FAX
EXISTINGUSE I PROPOSED LEE i CONSTR. TYPE I # STORIES
BldgApp_2011.doc revised 03/16/11
❑ OWNER ❑ OWNER -BUILDER OWNERAGENT ❑ CONTRACTOR ❑ CONTRACIORAGENT ❑ ARa=CT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME;/
LICENSE ER
LICENSE TYPE
BUS. LIC #
77 �_
U
COMP ANY NAME
E-MAIL
FAX
STREET ADDRES
STATE, ZIP
PHONE
ARCHTTECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANYNAME
E-MAIL
FAX
?
(
STREET ADDRESS
CITY, STATE, ZIP
PHQIE�
?SCRIPTION OF WORK / Y)'
EXISTINGUSE I PROPOSED LEE i CONSTR. TYPE I # STORIES
BldgApp_2011.doc revised 03/16/11