09100157I CITY OF CUPERTINO BUILDING PERMIT I
I BUILDING ADDRESS: 20875 VALLEY GREEN DR #56 1 CONTRACTOR: KORET FOUNDATION PERMIT NO: 09100157
OWNER'S NAME: KORET FOUNDATION
IER'S PHONE: 4082530200
❑ LICENSED CONTRACTOR'S DECLARATION
License Class
Contractor
Lic. #
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.
Sigrre Date.
L, 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
i• nify and keep harmless the City of Cupertino against liabilities, judgments,
c, 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. c
CionafiirP I 1 1 P,13/-"-.I0Y /VIJ k : Date
20875 VALLEY GREEN DR
CUPERTINO, CA 95014
DATE ISSUED: 10/23/2009
PHONE NO:
BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB r
MECH r- RESIDENTIAL f— COMMERCIAL I—
JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE,
COMMERCAIL
APARTMENT BUILDINGS
Sq. Ft Floor Area: I Valuation: $100
APN Number: 32609064.56 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date' �— Zw
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. 1 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, and 25534.
O n •ora horiz d ager ��,
%%d�/..K Date: i%12-31
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
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY ## : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32609064.56
DATE ISSUED.......: 10/23/2009
RECEIPT #.........: BS000009016
REFERENCE ID # ...: 09100157
SITE ADDRESS .....: 20875 VALLEY GREEN DR #56
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER KORET FOUNDATION
ADDRESS 20875 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: KAVITHA PENDYALA
CONTRACTOR .......: LIC # *OWNER*
COMPANY KORET FOUNDATION
ADDRESS 20875 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........
FEE ID UNIT
QUANTITY
AMOUNT PD
-TO -DT
THIS REC
----------
NEW BAL
----------
-----------------------
1BCBSC VALUATION
----------
100.00
--------------------
1.00
0.00
1.00
0.00
1BREMRECEP NO. OUTLETS
1.00
42.00
0.00
42.00
0.00
1BSEISMICR VALUATION
100.00
0.50
0.00
0.50
0.00
1EPERMITFE FLAT RATE
1.00
42.00
0.00
42.00
0.00
1MPERMITFE FLAT RATE
1.00
42.00
0.00
42.00
0.00
1PPERMITFE FLAT RATE
1.00
42.00
0.00
42.00
0.00
1PREPPIPE FLAT RATE
1.00
42.00
0.00
42.00
0.00
1TRAVDOC FLAT RATE
1.00
42.00
0.00
42.00
----------
0.00
----------
TOTAL PERMIT
---------- ----------
253.50
0.00
253.50
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
--------------------
NUMBER
----------------- ---------------
CREDIT CARD
253.50
AMEX
---------------
TOTAL RECEIPT
253.50
CITY OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
ogl�vt��
APN #Date:
Building Address: r
Q v C ca -4 ✓. 56
Mailing Address (if different from buildind address):
GAI-
Owner's Nar-P•
Koore4-
Phone #:
HOA: (Exterior work only) Yes U No [%
l
If yes, provide letter from HOA
Contractor:
Phone:
Fax: -
Contractor License #:
Cupertino Business License #:
Contact:
Phone: t-1 OF'-
F'-Fax:
r (
Fax:Y v�il- 4?? -S 10
Residential Commercial Fj
Job Description: ,
Building Permit Info:
^/
Bldg Rf Elect Plumb Mech Lid'
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B
A --Z
Square Footage:
Valuation: 100
Project Size: Express ❑ Standard Eg'*' Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at
Revised 02/05/09
OWNER -BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform
A. All the work authorized by this permit
B. A portion of the work
C None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. All of the work
B. A portion of the work (complete section below)
Contractor
Address/City. Phone #
State License #
Type of work to
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3. �/ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm
Address/City Phone Number
Type of work to be
erformed
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I declare under penaty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Information (reverse side).
Property Owner's Signature: Date: 10f 23Iv�
Job Address: JUM��I I� J �`' C.QN, -11 66, C heAfi vko CX Permit #
5C) iZ+-
Anv chanL-es to the information vrovided on this form shall be submitted to the Citv of Cuvertino Build
Department.