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11080052CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR OWNER'S NAME: 20800 VALLEY GREEN DR -)NIVNER'S PHONE: 4082530200 L LICENSED CONTRACTOR'S DECLARATION License Class Lic.# Contractor Date 1 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 1 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 CONTRACTOR: 20800 VALLEY GREEN DR 20800 VALLEY GREEN DR PERMIT NO: 11080052 DATE ISSUED: 08/08/2011 CUPERTINO, CA 95014 PHONE NO: BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH r RESIDENTIAL COMMERCIAL JOB DESCRIPTION: APT 499 - WASHER/DRYER INSTALLER Sq. Ft Floor Area: I Valuation: $100 APN Number: 32609040.00 I Occupancy Type: OWNER -BUILDER DECLARATION �follow m that I am exempt from the Contractor's License Law for one of he two reasons: 1, 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, am exclusively contracting with licensed contractors to construct t ject (Sec.7044, Business & Professions Code). ey 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, cogs, and expenses which may accrue against said City in consequence of the ig of this permit. Additionally, the applicant understands and will comply all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Sienature PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued b Date: 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, Chaper 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 Mangy gement District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Orv1►gr or a horiz agent: YY� I dt, I Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of NNork'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 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609040.00 DATE ISSUED.......: 08/08/2011 RECEIPT #......... BS000014340 REFERENCE ID # 11080052 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 VILLAGES AT CUPERTI CONTRACTOR LIC # *OWNER* COMPANY 20800 VALLEY GREEN DR ADDRESS 20800 VALLEY GREEN DR CITY/STATE/ZIP CUPERTINO, CA 95014 TELEPHONE ........: OPERATOR: patg COPY # : 1 QUANTITY AMOUNT PD -TO -DT THIS REC FEE ID UNIT --NEW-BAL- _ 1BCBSC VALUATION ----------- -------- 100.00 -- 1.00 0.00 0.00 1.00 44.00 0.00 0.00 1BREMRECEP NO. OUTLETS 1.00 44.00 0.50 0.00 0.50 0.00 1BSEISMICR VALUATION 100.00 44.00 0.00 44.00 0.00 1PREPPIPE FLAT RATE 1.00 1.00 130.00 0.00 130.00 0.00 1SUPINSFEE HOURS 1.00 44.00 0 44.00 1TRAVDOC FLAT RATE ---------- -- ---------- ------0_00 ---------- 263.50 0.00 263.50 0.00 TOTAL PERMIT : METHOD OF PAYMENT AMOUNT REFERENCE -- NUMBER ----- ----------------- CHECK --------------- --------------- 263.50 #3623 TOTAL RECEIPT 263.50 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingaQcupertino.org CUPER.TINO ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRE o / O V 4 L` e q / t e e n ID Z TW79 M♦ �� OWNER NAME NE CJ NE c � - O L E-MAIL STREET ADDRESS `J V CITY, STATE, ZIP J F ° JC ao 75 ll -e �V-e-�� Dv- C� e�floo C►4 45oty CONTACT NAME PHONE E MAII, /� C cNA - 1 rl-eV o - O 730C% 4109 --rim'- 1"14 014CO% STREET ADDRESSCITY, STATE, ZIP FAX 7v 0 eer D r -1:L 7 C U p e✓ir/Alk> C-4 46,0141 ❑ OWNER ❑ OWNER -BUILDER I�WNERAGENT ❑ CONTRACrOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS j CITY, STATE, ZIP PHONE DESCRIPTION OF WORK 1A EXISTINGUSE I PROPOSED USE I CONSTR. TYPE I # STORIES EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA s ` N " BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA W PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH q. ❑ ATTACH M DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES NN g« BEINGADDED? ❑ NO ADDMON? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNER'S NAME: "RE EEI,&1;4 PLANNING APDL K ❑ NO PLANNING APPROVAL.LFrrER 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 REQUIRED1�...:... ` New SFD or Multifamily dwellings: Apply for demolition permit for ` existing building(s). Demolition permit is required prior to issuance of building „0 permit for new building. _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosuresr n` �s form if any Hazardous Materials are being used as part of this project. Copy of Planning Approval Letter or Meeting with Planning prior to _ submittal of Building Permit application.5 .< EXVM Al B1dgAp,p2011.doc revised 03/16/11 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildina(a)cuoertino.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 j�JAP7N a o G auU-6z✓,0f2 BP# OWNER NAME OWNER ADDRES ff U4 6 I� V P�2vl DESCRIPTION OF WORK: l� S f-�Gs72 /2 UG Db Uig We are providing you with an Owner-Buiider 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 iWracoverage for injuries to workers on my property. nderstand 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. V�. I 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 ;e in tead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license number on ;struction and contracts. if I employ or otherwise engage any persons, other than California licensed Contractors, and the is at least five hundred dollars ($500), including labor and materials, I may be Xderstand an "employer" under state and federal law. 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. Wk�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 perforTned under contract with a licensed general building Contractor. WA -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. OianaerBuilderForm 2010.doc revised 04/14/10 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 www.csib.ca.gov for more information about licensed contractors. 1/1�" e. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the rty legally and financially responsible for proposed construction activity at the site address listed above. 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide y all a licable laws and requirements that govern Owner -Builders as well as employers. 2. 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. 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 si nafure. _ g Property Owner's Signature: Date: --------------------------------------------------------------------------------------------------------------------------------------------- (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. p Scope of Construction Project (or Description of Work): i ID Project Location or Address: ,,O eDO V Q po �`---- Name of Authorized Agent: r /i JPw- Tel No We q11_&113V Address of Authorized Agent: 2 0 g T,5 J14 Ille -i � Av_e� 41P 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: �) ► (mac�� l /��`�' Date: 8 0mnelBuilderForn7 2010. doe revised 04/14/10