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09080098CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20875 VALLEY GREEN DR UNIT 62 CONTRACTOR: TBD - TO BE DETERMINED I PERMIT NO: 09080098 OWNER'S NAME: KORET FOUNDATION t ER'S PHONE: 4082530200 ❑ LICENSED CONTRACTOR'S DECLARATION License Class_ Lic. 4 Contractor Date 1 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 for which this permit is issued. 1 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. 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 upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all rion-point source regulations per the Cupertino Municipal Code, Section 9.18. Date at OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the tollowing two reasons: 1, as owner of the property, or my employees with wages as the. sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct :he project (Sec. 7044, Business & Professions Code). 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 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 permit is issued. 1 certify that in the performance of the work for which this permit is issued, I shall 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 become 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 1 certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances :-nd state laws relating to building construction, and hereby authorize representatives of this city to enter ur the, above mentioned property for inspection purposes. (We) agree to save j r;'y and keep harmless the City of Cupertino against liabilities, judgments, ' cow,. and expenses which may accrue against said City in consequence of the graniing of this permit Additionally, the applicant understands and will comply with all :?on -point source regulations per the Cupertino Municipal Code, Section 9.18. � Signaittt<e _ _ �� Vim•!'`! Dates DATE ISSUED: 08/11/2009 PHONE NO: BUILDING PERMIT INFO: BLDG ELECT PLUMB' MECH f— RESIDENTIAL COMMERCIAL, f— JOB DESCRIPTION: INSTALL WASHERIDRYER UNIT SINSIDE COMM'L APT. BLDGS Sq. Ft Floor Area: I Valuation: $100 APN Number: 32609064.62 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAY FROM LAST CALLED INSPECTION. SIssued by: e -l). � 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, 1 agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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 i will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or auth rued . end�,, W Aj Date• I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec 3097, Civ C.) Lender's Name CITY Of CUPEkTINO 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 wry w.builditret nor?, Revised 02/05/09 Building Address: 22 uildin address): -- Mailing Address (if different f7C., Owner's Nar--• F01AAdcJ4,e�kA Phone : 110A: (Exterior work only) Yes Lj No 1% Y If yes, provide tetter from HOA Contractor: Phone: Fax: Contractor License Cupertino Business Licenqe #: Contact: Phone:g ..t i G 7G3 �fj ,f Fax.: ", � .. . -. io 2..-. Residential Commercial El Job Description: Wc- Building Permit Info: -� Bldg Ll�f Elect ( Plumb I( lblech � Type of Construction (Osage Class): Occupancy Type: 1-A I-BII/III/V-A 11/111 B, ISI -HT V -B 0 —2 Valuation: 10,0 Square Footage: Project Size: l"x rens E] Standard Lar Ma`or Ej 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 wry w.builditret nor?, 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 authorized by this permit B. �A portion of the w ork 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 - npulers aK PLUM J9/ w G d'os S o AJ, s 44 We 4 7 5 31-206 - $doe �v V�.Row /�ttr'7'+hvuS 38 O S r—63Y-O6 L Z 906 q4' 5. Sr4.N c Ifo 3. y 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' cor:ipensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed 7-0 V L 6r3 .3Z6 C / Fv1en-&e 133- 5 - 13210 PLUM J9/ w G w ro.jso j -L& o AJ, s 44 We 4 7 5 31-206 - $doe �v P A-dJ J -o I declare under penalty of perjury that the at-ove is true and correct. I have read and understand the Owner -Builder Information (reverse side). ��(( Property Owner's Signature: ' Date: X51 i Job Address: J067S \1116A110JffiA1AJArf, :#48,CA Permit # Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. CITY OF CUPEkTINO CITY OF ("..UPERTINO GENERAL BUILDING APPLICATION FEE SCZEDULE Quantity/Sf Fee ID Fee Description 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 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing; Permit Fee P lELCPLNCK 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 -stmd alone B 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic JZesidential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel & Documentation B 1BUSLIC Business License B VMk- 1"5 Wof I ---- / p9q, ?