11080175 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 11080175
DR
OWNER'S NAME: 20800 VALLEY GREEN DR 20800 VALLEY GREEN DR DATE ISSUED:08/23/2011
'NER'S PHONE: 4082530200 _ CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALE]
License Class Lic.# APT#455-INSTALL WASHER/DRYER HOOKUP
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
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 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 DAY rC"
M LAST CALLED INSPE TION*
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Issued fit'
costs,and expenses which may accrue against said City in consequence of the Id b Date: v
granting of this permit. Additionally,the applicant understands and will comply y'
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.
u7K4_ WNER-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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
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. 1 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,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 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 25505,2553 , 25534. /
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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 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 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
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 construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
-�mnify and keep harmless the City of Cupertino against liabilities,judgments,
.s,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 the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature�)�IA r r/ Date
CITY OF CUPERTINO
6 ITEMS OF 12 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN 32609040. 00
DATE ISSUED. . . . . . . : 08/23/2011
RECEIPT #. . . . . . . . . : BS000014541
REFERENCE ID # . . . : 11080175
SITE ADDRESS . . . . . : 20800 VALLEY GREEN DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER 20800 VALLEY GREEN DR
ADDRESS 20800 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : UBS
CONTRACTOR LIC # *OWNER*
COMPANY 20800 VALLEY GREEN DR
ADDRESS 20800 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 500 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 500 . 00 0 . 50 0 . 00 0 . 50 0. 00
1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1SUPINSFEE HOURS 1 . 00 130. 00 0 . 00 130 . 00 0. 00
1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 263 . 50 0 . 00 263 . 50 0 . 00
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
(408)777-3228- FAX(408)777-3333- building(a-Dcupertino.org
CUPERTINO
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 /? � ss
APN BP#
OWNE M (' OWN.E2RvDCR/ � vG G ✓2 2vv
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 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.)
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.
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.
XtWI 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.
A4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
14�Iunderstand if I employ or
otherwise ve hundred dollars r($500),ther than California including laborandlmateeals ,Contractors,may beand the
total value of my construction is at least
considere.d an "employer" under state and federal law.
_44�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.
&IFI-u-nderstand 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.
I 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.
O4,nerBuilderForm_2010.doc revised 04/14/10
TVA` 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
Z
710.
rs.
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.
11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
;z:e
e laws and requirements that govern Owner-Builders as well as employers.
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.
CONSTRUCTION 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 verification acceptable to 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: g3 lZo-al
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):--T U ✓
Project Location or Address: o8 D00 &Q�A^- ti S
Name of Authorized Agent: 1 CG-) 4e-/ pUl h-eJ Tel No
Address of Authorized Agent: 2 D 75 r D
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form 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
signature. -
Property Owner's Signature: Date:
12,3 Ili
Ownel'BuilderForm 2010.doc revised 04/14/10
CONSTRUCTION PERMIT APPLICATION
12 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777- 228 • FAX(408)777-3333 •building cDcugertino.org I 'O�'�
❑NEW CONSTRUCTION ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS0 ``C� r �� (# / APN#-1 0 50 / �O
OWNERNAM(E PHONE 7 (O E-MAIL
253- 0 2 0 o
STREET ADDRESS CITY, STATE,ZIPFAX
VA-(,UCq Gre2N b2 Cc>rPev2rlr�Je 50l
CONTACT NAME PHONE E-MAIL
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STREET ADDRESS CITY,STATE ZIP FAX
2 �e -t41 rZ CV�d44_7_ .d0 S
❑OWNER ❑ OWNER-BUILDER OWNERAGENT ❑ CONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMP ANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGINEERNAME LICENSE NUMBER BUS.LIC#
COMP ANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
EXISTINGUSE PROPOSED USE CONSTR.TYPE #STORIES
NOW
UN
EXISTG NEW FLOOR DEMO TOTAL w �
..
AREA AREA AREA NET AREA . " ` v
BATHROOM KITCHEN v mow$00 OTHERREMODEL AREAREMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA:❑ DETACH
❑ ATTACH
N DWELLING UNRS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES WDA� � ` •'_ ',y�
BEING ADDED? NO ADDITION? NO �rsc
W,
PRE-APPLICATION ".
❑YES IF YES,PROVIDE COPY OF PLANNER'SNAME: $ _
PLANNING APPL N ❑NO PLANNING APPROVAL.LEITER °"' `& -
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED :. s.. .,
. .oc�xtt� s;
New SFD or Multifamily dwellings: Apply for demolition permit for �*
existing building(s). Demolition permit is required prior to issuance of buildingo`
permit for new building.
P g
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
formsTAtitty tIs �va
if any Hazardous Materials are being used as part of this project. mm
_Copy of Planning Approval Letter or Meeting with Planning prior to
ubmittal of Building Permit application. IvrAaaR RX`� � ,x
BldgApp MLdoc revised 03/16/11