09120056 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20990 VALLEY GREEN DR APT 6 f CONTRACTOR:KORET FOUNDATION PERMIT NO:09120056
OWNER'S NAME: KORET FOUNDATION 20990 VALLEY GREEN DR#600 DATE ISSUED: 12/09/2009
NER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB
License Class Lic.#
MECH f- RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that 1 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.
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 Sq.Ft Floor Area: Valuation:$100
permit is issued.
APPLICANT CERTIFICATION APN Number:32609053.APT06 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ,,
Issued by-'. Date-/2
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(See.7044,
Business&Professions Code) Signature of Applicant: Date:
1,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
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
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
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authoriz da nt:
forthwith comply with such provisions or this permit shall be deemed revoked. -~. Date: 01
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
ipd-mnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
g,_ang 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
9.18. 1 understand my plans shall be used as public records.
Signature7ba'k k Y\_AM^Date Z Licensed Professional
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by thds 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. :Z A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
t�vYc 1-�l e aJ o- 6
�.sDIA
3. _ I will utilize unlicensed person(s) other than my immediate fancily 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' corlpensation must be on file at the City of
Cupertino Building Department office.
PersorVTirm Address/City Phone Number Type of work to be
erformed
b 32(, CA•KCrfg Iyt83 3 - 8.260
kw<o A•r i<<c SA
Q T2_> �$- 2S3• 0200 PIU-M-6 14-P
' eih c
............................................................................. .......................................................................................................
I declare under penalty of perjury that the alcove is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: Cr� A�� Date:
Job Address: 02 Oq q O � � d f 4 6'i 1 tAvL0, CA Permit# �
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
cirY of
CITY OF ..UPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date-
3Z6
Building Address:
Mailing Address (if different from building addr ss):
c c.�
Owner's N e: Phone#:
",L f CL CCK Li O -
HOA: (Exterior work only) Yes ❑ No zs�
If yes,provide letter from HOA
Contractor: Phone:
Fax:
Contractor License
;r
Cupertino Business License
Contact: . Phone:
TL.-Ij e✓
Fax: 90L X73 - Io ZS'
Residential Commercial El
Job Description:
LLe
Building Permit Info: �/ —/
Bldg Elect 1� Plumb Mech
Type of Construction(Usage Class): Occupancy Type:
1-A 1-B El II/III/V-A IUIII B IV-HT, V-13 A r z .
Valuation: / 0a Square Footage:
Project Size: Express ❑ Standard [v *" Large [] Major ❑
Green Building: Please complete relevant portion )f the Green Building/LEED Checklist& attach it
to the application or if applicablf, include in plan set & the sheet index.
Points Achieved:
lFor help, contact Build it Green at www.builditrf en.or
Revised 02/05/09