09100075 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20990 VALLEY GREEN DR APT 669 CONTRACTOR:KORET FOUNDATION PERMIT NO:09100075
OWNER'S NAME: KORET FOUNDATION 20990 VALLEY GREEN DR#600 DATE ISSUED: 10/12/2009
NER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT F PLUMB f—
License Class Lic.#
MECH f— RESIDENTIAL f— COMMERCIAL
Contractor Date
I 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. APARTMENTS BUILDINGS
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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$100
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:32609053.669 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 180 DAYS FROM LAST CALLED INSPECTION.
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. "" _ - „ /1Z
2�l
Issued by: Date:
Signature Date
Q, OWNER-BUILDER DECLARATION RE-ROOFS:
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 stricture 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
1 hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's 1 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
permit is issued. 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
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 Owner or an orized agent
become subject to the Worker's Compensation provisions of the Labor Code,I must l (/ �_�t/�n�-i-2—�f--bate: -JO /�44 '�/
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION 1 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
it nify and keep harmless the City of Cupertino against liabilities,judgments,
L and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
�f D Licensed Professional
Signature JCIt-C�.-�. ��'✓t-�'�, Date � 12-
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32609053 .669
DATE ISSUED. . . . . . . : 10/12/2009
RECEIPT #. . . . . . . . . : BS000008887
REFERENCE ID # . . . : 09100075
SITE ADDRESS . . . . . : 20990 VALLEY GREEN DR APT 669
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 . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : KORET FOUNDATION
ADDRESS . . . . . . . . . . : 20990 VALLEY GREEN DR #600
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 CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# 3Z6 — 0 ,7 — rr Date-
Building Address:
Z o O V u ��e G✓e e� ��
Mailing Address (if different from building addr ss):
Owner's Ne: Phone#:
O r � D
HOA: (Exterior work only) Yes E] No � Z�� C� 2- d
If yes, provide letter from HOA
Contractor: Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: � .G�a G fi Phone: 572-7e c/3
Fax:Residential Commercial Commercial ❑
Job Description: 6 0 &-A Ap" 11d:
7
Building Permit Info:
Bldg Elect Plumb !1d' Mech
Type of Construction (Usage Class): Occupancy Type:
1-A I-B II/III/V-A II/III B, IV-HT, V-B N?/ A — z
Valuation: Square Footage:
r
Project Size: Express ❑ Standard E?"' 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.buflditgreen.org
Revised 02/05/09