11030080 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 432 CONTRACTOR:UBS PERMIT NO: 11030080
OWNER'S NAME: UBS 20800 VALLEY GREEN DR DATE ISSUED:03/16/2011
OWNER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO:
L LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH F RESIDENTIAL� COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APT 432-INSTALL WASHER&DRYER UNITS INSIDE
(commencing with Section 7000)of Division 3 of the Business&Professions COMM'L APTMENT BUILDINGS
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 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:32609040.432 Occupancy Type:
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 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. Issued ---�" Date-3 `
Signature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I ncreby 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 ject(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I re�under penalty of perjury one of the following three MATERIALS DISCLOSURE
declarations: HAZARDOUS
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 Owner or authorized agent:
iW4 \b
become subject to the Worker's Compensation provisions of the Labor Code,I must C�+-�' ntiµ�' 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 Hork'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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
ng of this permit.Additionally,the applicant understands and will comply
all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
,tet, Licensed Professional
Signature `9 lf, Date r/
LIJIOWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• buildina5cuoertino.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 APN BP#
66 LL e y 2�G 1J i2 z -O CRUD-- Y3L
OWNER NAME OWNER ADDRESS
08.12
G cLe� - G1J
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.)
�. I 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.
7A4: F2. I understand building permits are not required to be signed by property owners unless they are responsible for
�1,,�th�e construction and are not hiring a licensed Contractor to assume this responsibility.
/��y�-' 3. 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
�1
name instead of my own.
/9VI4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
?n1,t(5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
r'--
?R446. I 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.
A4 7. I 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 performed under contract with a licensed general building Contractor.
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.
Oia,nerBuilderForm 2010.doc revised 04/14110
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY ## 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32609040.432
DATE ISSUED. . . . . . . : 03/16/2011
RECEIPT #. . . . . . . . . BS000012915
REFERENCE ID # . . . : 11030080
SITE ADDRESS . . . . . : 20800 VALLEY GREEN DR APT 432
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . UBS
ADDRESS . . . . . . . . . . : 20800 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : VILLAGES AT CUPERTI
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . . UBS
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 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
1PREPPIPE FLAT RATE 1 . 00 42 . 00 0 . 00 42 .00 0. 00
1SUPINSFEE HOURS 1 .00 126 . 00 0. 00 126 .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
----------------- --------------- --------------------
CHECK 253 .50 #3303
---------------
TOTAL RECEIPT 253 . 50
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date:
C( - 0 CIO
Building Address:
�2 o olo V6, 1 6) 13
Mailing Address (if different frr building address):
7c G-
Owner's Name: J Phone#:
U I?
HOA: (Exterior work only) Yes U No
If yes, provide letter from HOA
Contractor: `' Phone:
J Fax:
Contractor License#:
Cupertino Business License#:
Contact: a Phone: L40S. ZSR-7� 3
Fax:
Residential Commercial ❑
Job Description:
o vac e✓Lt.0 14 f3,j Jd -ujs-
Building Permit Info: —/
Bldg Elect ( Plumb [1K Mech L�
Type of Construction (Usage Class): Occupancy Type:
I-A 1-B El II/III/V-A ❑ II/III B, IV-HT, V-B 14- 7—
Valuation:
4_ 7—
Valuation: Square Footage:
Project Size: Express ❑ Standard E?r 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.
'oints Achieved:
For help, contact Build it Green at www.builditgreen.org
Revised 02/05/09