09100017CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 305
CONTRACTOR: TBD - TO BE DETERMINED
PERMIT NO: 09100017
OWNER'S NAME: KORET FOUNDATION
DATE ISSUED: 10/05/2009
'ER'S PHONE: 4082530200
,
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
F f-
MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: INSTALL WASHER & DRYER UNITS INSIDE
(commencing with Section 7000) of Division 3 of the Business & Professions
COMMERCIAL
Code and that my license is in full force and effect.
APRTMENT BUILDING; APT #305
1 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: $100
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.
APN Number: 32609041.305
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
180 D YS FROM AST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code, Section
�% 9
9.18•
Issued by./"i/ d / Date:
Signature Date
RE-ROOFS:
I� OWNER-BUILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
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,
Signature of Applicant: Date:
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 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
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued, I shall
Health & Safety Code, Sections 25505, 25533, and 25534.
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
Qwner or thoriZediag n
M
V 1 l nAA14 I Iq
become subject to the Worker's Compensation provisions of the Labor Code, I must
1 ,Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
i- •iify and keep harmless the City of Cupertino against liabilities, judgments,
C, :nd expenses which may accrue against said City in consequence of the
ARCHITECT'S DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
+ ' Date 0 51 o
Licensed Professional
Signature
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32609041.305
DATE ISSUED.......: 10/05/2009
RECEIPT #.........: BS000008822
REFERENCE ID # ...: 09100017
SITE ADDRESS .....: 20975 VALLEY GREEN DR APT 305
SUBDIVISION ......
CITY .............. CUPERTINO
IMPACT AREA ......
OWNER ............: KORET FOUNDATION
ADDRESS ..........: 20990 VALLEY GREEN DR #600
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: KAVITHA PENDYALA
CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096
COMPANY ..........: TBD - TO BE DETERMINED
ADDRESS ..........
CITY/STATE/ZIP ...: ,
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
,g A,9-01,.9
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. 7 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 penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Information (reverse si e).
Property Owner's Signature:
Date: C) 1's I U
Job Address: A�3U� cth�o C"A Permit#
Anv changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
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APN# 3Z6-ol?
Date: • � _
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Building Address: O q75- F j /� �
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Mailing Address (if differe t from building addr ss):
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Owner's Name: LA /
Phone #:
HOA: (Exterior work only) Yes U No rX
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If yes, provide letter from HOA
Contractor:
/
Phone:
Fax:
Contractor License #:
Cupertino Business License #:
Contact:
Phone: L4 o $- .2y2 -76 e13
Fax: Lfog- q7 - c> -ZS -
Residential Commercial
Job Description:
If
Building Permit Info:
_
Elect Plumb ' Mech
BldgU/1—Lr
Type of Construction (Usage Class):
Occupancy Type:
1-A, I -B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B
- 4 -2 -
Valuation:
/0b
Square Footage:
Project Size: Express ❑ Standard V 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 www.builditgreen.org
Revised 02/05/09