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13040086
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRACTOR: KORET FOUNDATION PERMIT NO: 13040086 OWNER'S NAME: KORET FOUNDATION 1050 RALSTON RD DATE ISSUED: 04/10/2013 OWNER'S PHONE: 4082530200 BELMONT, CA 94002-2243 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11COMMERCIAL 13 License Class Lic. # UNIT # 301 - NEW WASHER AND DRYER HOOK UPS Contractor Date 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. 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. Sq. Ft Floor Area: Valuation: $500. . I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32609041.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITfIIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY T CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issue Date: 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. '. Signature Date E-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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the:following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, 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 (See.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044; Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous. I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sectio ;5505,25533, ad 25534. Section 3700 ofe Labor Code, for the performance of the work for which this thgent Owner or authorized: Dater-��'—�� permit is issued. I 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 CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally,thea licant understands and will comply with all non-point source regulations per a Cupertino Municipal Code, Section Licensed Professional 9.18.: Signatur Dam ' DESCRIPITONOF WORK `U -O . EXLSTINGUSB PROPOSED ISE CONSUL: TYPE - #STORIES •IXLSTQ NEWkZ0012 •DEbfO TOTAL [ 1O _ ; T C` //`"� V ��I `�� I^KLI� f IviF� I�',41I_.i e ._ i-- . J .?^'L...'1�-`. BATM06M :REN10DIIrAREA..REMODELAREA•i=. PORCHAREA DECKe1REA TOT4ILDECK/PQRG3AREA G?.TLAGE II DETP.CEL'- � ❑.'ATTACEV #DWES.L.I cI ElmS 7SASECOPIII TIl`II2 '.: YES SECOI`m STORY YES . (�NEWCO�ISTRUCTION ADDr%iON Pi'Cn•APPLiCp.EON 3 II YES �- 7F Yn5,PROVIDE J ALTERATION T1 I_J _R:,:ViSION/DEr ��D ORmi=ti�T PE-Zti1T= CO�YOL'PLAN[ZERSNAME. [� NO PLANKNOAPPROVALSEIrm PROJECT ADDRES:' a3N = OWNER NAMEPrrON-„ -1912 at 7-STRr=.T -MAM 1/N fly C'"� K Z3 (U�if1 E ADDREss ? I cry. r, SrAi rP W3 9-1 Y&--/ I FAx CONTACT NAMEPfiONE /- - n ,^ g_M,yJI, , V STREET ADDRESS _ 2 , �y,�/- Tr, STA �Z jr l� FAX OVR ER ❑ 0'111 LBUIIDER ❑ OWMMAGENT ❑ COITIRACIOR ❑ CONTRACIORAGENI• ❑_ ARCAITECT O FN.M, ❑ DEVELOPER ❑ TENANT CONTRACTOR NA.&B- LICENSE WO&MERZ, LICENSE TYPE (J, , COMPANYNAME R\ ` E/7 DOW J E-MAIL FAX STREET ADDRESS�� CITY, STAT d /7 j PONE one K l rni al �l �1 - ARCHTTECTIENGIlEER NAME V LICENSE NUMBER BUS. LIC # - COMPANYNAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPITONOF WORK . EXLSTINGUSB PROPOSED ISE CONSUL: TYPE - #STORIES •IXLSTQ NEWkZ0012 •DEbfO TOTAL AREA AREAr : •` AREA . NETAREA BATM06M :REN10DIIrAREA..REMODELAREA•i=. PORCHAREA DECKe1REA TOT4ILDECK/PQRG3AREA G?.TLAGE II DETP.CEL'- � ❑.'ATTACEV #DWES.L.I cI ElmS 7SASECOPIII TIl`II2 '.: YES SECOI`m STORY YES . - BEIIYGADDED • .�",j NO •, ADDEl'10N?' .r.7 NO - Pi'Cn•APPLiCp.EON 3 II YES �- 7F Yn5,PROVIDE , PLAI'1lVINQAPPLY CO�YOL'PLAN[ZERSNAME. [� NO PLANKNOAPPROVALSEIrm CITY OF CUPERTINO WPM 1 F.F. 1PQTI1%4ATnR — RITII.11ING I)IVIRION imADDRESS: 20975 VALLEY GREEN DR # 3017 DATE: 04/10/2013 REVIEWED BY: MELISSA APN: 326 09 041 BP#: "VALUATION: $500 —� *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Du lex p hrs PENTAMATION 1RMAP1 USE: PERMIT TYPE: WORK NEW WASHER AND DRYER HOOK UPS Permit Fee:. $0.00 SCOPE 0,0 Mech. Plan Check 0.0 1 hrs $0.00 Phimb. Pleat Check I IElec. Plan Check Mech. Permit Fee: IA PERMIT Plumb. Permit Fee: Elec. Permit Fee: Other Mech. Insp. hrs $45.00 Other Plumb Imp.Other Elec. Insp. 0.0 0 Alech. Imp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee: AInTF- Thi.c ectimnte does not include fees due to other Departments (Le. Planniniz, Public Works, Fire, Sanitary Sewer District, trict IPA These ees are based on the relimina information available and are on/v an estimate. Contact the De t or addn'1 in FEE ITEMS (Fee Resolution 11-053 E . 7111122 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 2 # Mechanical $134.00 1BAPPLOT Other Appliance/Equip Suppl. PC Fee: (E) Reg. 0 OT 0.0 I hrs $0.00 PME Plan Check: $0.00 Permit Fee:. $0.00 Suppl. Insp. Feer Reg.- Q OT 0,0 hrs $0.00 PME Unit Fee:. _ $0.00 PME Permit Fee: $45.00 Construction Tax: J7 -- Administrative Fee: 1ADAffN $42.00 . 0 Work Without Permit? 0 Yes E No $0.00 Advanced PlanningFee . $0.00 Select a Non -Residential Building or Structure i Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldjz Stds Commission Fee: IBCBSC $1.00 $133.50 $134.00 ®T� $267.50 �\ , Revised: 04/61/2013 U E j r�f(f4i illi' _✓=1 v< <' -� ._�' ,I -i\ t I� �: _I JN j i0500TrJ?R-, V=h'U Cl'-T!�'O,C^ 9-0 1 -32 5 (403) 777-3223 ..=AX (40.3) 777-3333 • b:jdh:-- Dear Property Owner(s): An application fora buiiding permit has been submitted in yoiir name listing yourself as the builder of the property improvements specified at: 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, initiated your understanding of each provision, signed, and returned this form to us at our officiat address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permittingauthority. OWNEWS AGKNOWLED.GMENT AND VERIFICATION OF INFORMATION (DIRECTIONS. Please read and initial each statement below to signify you understand or verify this information.) 21. 1 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 ocher employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am witffully acting as an Owner. -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 5 � 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responslbifity. 9. i understand I may obtain more information regarding my obligations as an :'employer'from the Internal Revenue Sen/ice, the United States Small Business Administration, ii' e CaiiiOmla i e; aii e%t Of On2i t aymOntS, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800 -321 -CSL B (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. S 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, i will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. V12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to :assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. it is also important for you to understand that if an unficensed Contractor or .employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not ';those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency ihformation.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and. returned to the agency responsible for issuing the permit. Note; A copy of the properly owner's driver's /icense, forrn.notarization, or other verification acceptable to the city ma be requlred to be presented when the permit is issued to Verify the property ownei's si nature. Property Owner's Signature: Date: <.... - -- - --- ---- ----------------------- ------ (N©TE. , The following,Authorizatian Formas required to b.e completed by the property owner ohly when designating an agent of the properly owner to apply.for a 'construction permit for the Owner -Builder). F._ AUTHORIZATION:AFAGENTI TO ACTON PROPERTY OWNEWS. BEHALF (Address ofApthonzed Agent 3 F, I declare under pena(ty of per}ury, that I arra the prop" owner for tie address listed ave and 1 perso^a;ly fll°d alit the `above information aril ceii fy its_accurapy Note : A copy of the property owner's driver's 11 se, form notarization; or other:: verification acceptable to the city may be required to be presented when the permit is issued to verify the property oivner`s (.Owner's Signature: Date: UrvnerBuddetFbrm 2010.doc revised g4ll4/10 = - CUPERTINO Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: 20I PERMIT #-- .30Y'60 OWNER'S NAME: 1i('0 % 'm/ PHONE # GENERAL CONTRACTOR: "fb( e -aa QR� BUSINESS LICENSE.#. 206 ADDRESS: e CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete.the following information:. caner [Contractor Signature Date s: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile caner [Contractor Signature Date s: