09080099CITY OF CUPERTINi0 BUILDING PERMIT I
BUIi PtNG ADDRESS- :02575 VALLEY GREEN DR UNIT 48
OWNER'S NAME: KOR1'T FOUNDATION
.R`S PHONE: 4082530200
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lie. #
Contractor
I 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.
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 fol which this permit is issued.
I have anc 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
i certify that 1 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 bi.ilding construction, and hereby authorize representatives cf this city to enter
upon the above ment oned pfoperty, for inspection purposes. (We) agree to save
indclnnify and keep harml,ss the City of Cupertino against liabilities, judgments,
costs, and expenses wHch ntav accrue against said City in consequence of the
granting of this permit. A: dit:onally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature _.
Date
9) OWNER -BUILDER DECLARATION
i I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons;
1, m owner of the property, or my employees with wages as their sole compensation,
i will do the work, and the situcture is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as o N,.et of the property. am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1
I hereby affirm under penalty of perjury one of the following three
declarations:
1 have ar,d 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 .' .orker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit �s issued.
I certify that in the performance of the -Mork for which this permit is issued, I shall
not employ any person m any manner so as to become subject to the Worker's
Compensation laws of Cz!ifornia. If, after making this certificate of exemption, I
becoma 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 certifv that I have read this application and state that the above information is
correct. I agree to comply with all city and count; ordinances grid state laws relating
to buiiding construction, and hereby authorize representatives cf this city to enter
I up the above mentioned property for inspection purposes. (We) agree to save
ify and keep harm!ess the City of Cupertino against liabilities, judgments,
t and expenses which rrjay accrue agaiusr said City in consequence of the
granting of this permit Additionally, the applicant understands and will comply
with all non -point souse regulations per the Cupertino Municipal Code, Section
9.18.
j Signat+ate--
CONTRACTOR: TBD - TO BE DETERMINED PERMIT NO: 09080009
DATE, ISSUED: 08/11/2009
PHONE NO:
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH f RESIDENTIAL F COMMERCIAL
JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE
COMMERCIAL
APRTMENT BUILDINGS
Sq. Ft Floor Area: Valuation: $100
APN Number: 32009064.48 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM AST CALLED INSPECTION,
Issued by: �� y 'G Date:
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
1 have read the hazardous materials requiremepts under Chapter 6.95 of the
California Health & Safety Code, Sections 25.505, 25533. and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 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 ! will
maintain compliance with the Cupertino Municipa". Code_ Chapter 9.12 and the
Health & Safety Code,.Sections 25505, 25533, and 25534.
Owner or authorized a ent t
_ DateF%J jib
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction !ending 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 Professio
oqo� oo�q
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #
Date: /Oc7I
Building Address:
#` e
Mailing Address (if different from bui Idind address)
Owner's Nam— {rs. Phone ##:
K- 4 y j
�"� o� �j C
IIUA: Exterior Work only) Yes L_j No
If 'es, rovide tetter from HOA
Contractor:
Phone:
Fax:
Contractor License ##: Ll
Cu ertino Business LicenRe #;
Contact:
Phone:
j `
F
Residential commercial
Job Description: vj
Building Permit Info:
Bldg, Nf Elect
"lumb Mech
Type of Construction (Usage Class):
Occupancy Type:
A
___z
- - IIJIII,Y-A IIIIII B, IV -HT, V -It
1A,lB(�
—z
Valuation:
Square Footage:
Pro'eet Size: l x rens Standard
Large Ma'or
reen Building- Please complete relevant portion (if the Green Buildin�El�T7► Checklist S attach it
g
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For hel , contact Build it Green at www.buildit reen-or
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 authcrized 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
ev ,?- .
I -D eZA PJ Gd 8 G14 q9r, a4(oS
ikcftia.
oKcJA WX
SaA&To�f-
D
I tVMw u9-9
585 0464eA P� 131 !o bo - 6 34 OU 2g o6
-2
3. 1/ 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
performed
VpbeA
3,2 (6 311- E531 -19,z,50
A)CJS0-VLV4fte GV
oKcJA WX
Igo 6' 31-a06-8�To
OSe Ck
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Information (reverse side).
Property Owner's Signature: a Date:
Job Address: # %2 6xpuhM Permit #
Anv changes to the information Provided on this form shall be submitted to the Citv of Cupertino Build
Department.
CITY OF
CUPERTINO
CITY OF CUPERTINO
GENERAL BUILIIING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Des -.ription
Fee
Group
Permit Type
1GENRES or
1GENCOM
1STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows)
B
1 WINMEWSTR
New Window -structural shear
wall/masonry (includes plan ck fee)
B
r
l
1EPERMITFEE
Electrical Permit Fee
E
1 MPERMITFEE
Mechani :al Permit Fee
M
1 PPERMITFEE
Plumbing Permit Fee
P
IELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1 MECPLNCK
Stand Alone Mechanical Pln, Ck (hrly)
M
1PLMBLNCK
Stand Alone Plumbing Pln Ck (hrly)
P
1 STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourl -stand alone
B
1BCBSC
Cal Bld€, Standards Commission Fee
B
ALL PERMIT
TYPES
r
l
1BSEISMICR
Seismic Residential
B
1BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel 8; Documentation
B
1BUSLIC
Business; License
B
04-1W-ff 5a„ 1 okq
P,�e�