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13040085CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRACTOR: KORET FOUNDATION PERMIT NO: 13040085 OWNER'S NAME: KORET FOUNDATION 1050 RALSTON RD DATE ISSUED: 04/10/2013 OWNER'S PHONE: 4082530200 BELMONT, CA 94002-2243 PHONE NO: JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALE] ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lica# "UNIT # 209 - 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 3,700 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 Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 32609041.00 Occupancy Type: 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 WITHIN 180 SOF 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 D AST 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 L l0 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. RE -ROOFS: Signature Date 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 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, Business & Professions Code) I, 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 Municip Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Seed 5505, 25533gn 25534. Section 3700 of the Labor Code, for the performance of the work for which this A Owner or authorized agen Date: / JO permit is issued. I certify thatin 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, aftei 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, the applicant understands and will comply With all non -point source regulations. p/theupertino Municipal Code, Section Licensed Professional 9.18. Signature i Date ` r 'CONSTRUCTION PERPOI i APPLICATION �O N CON 1MUNI I Y DO,/ELC MEN T 0==",?Ti;i=: i U1=D1 1G DI'J IS O v 10300 TORRE ; .RE VENUE • CUPST'INO, CA, 95014-325c- � jV I (408) 777-3228 • FAX (408) 777-3333 • buildinaE�curgerir.o.o,a `J F-1 WPW C'(T7CTRTTC-rTnTT I -I A. 1111111/ I I x r mr,,, . �.+.,,, n ._.__-.._.._- •-------- --- ---- - PROTECT ADDRES ...... 2a g I APN 312- 6 © 10V Z _. . '(;J 7'4J / 1. PHONE ❑. ARCFTTTECT ❑ ENaDMER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME - STREET ADDRESS CITY, STATE, Z I I FAX r• CONTACT NAME PHONE E-MAIL FAX STREET ADDRES Y .�1►� STREET ADDRESS ® CITY TATE. ZIP r n� -&41, (' FAX ARCHTTECT/ENGIl�ER NAME v LICENSE NUMBER gk,OWNER ❑ OWNER-BURDER ❑ OWNERAGENT - ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑. ARCFTTTECT ❑ ENaDMER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME - LICENSE NUNMI R ; a, &. -LICENSE TYPE .. __., �,� - BUS. LIC # COMPANY NA?,M E-MAILr OSA FAX STREET ADDRES Y .�1►� CITY, STAT$ O PHONE q U ARCHTTECT/ENGIl�ER NAME v LICENSE NUMBER BUS. LIC # CONIPANYNAME E MAII =: FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXLSnNGUSE PROPOSED LSE • CONSUL TYPE # STORIFS EXLSTG NEWFLDOR DEMO _ TOTAL AREA AREA AREA.. NETAREA. BATHROOM .. . OTHER REMODEL AREA. .... REMODELAREA - REMODELAREA rB REA DECK AREA TOTALDECK/PO$CHAREA GARAGEARft'❑ DETACH ❑ ATTACH Ieux=&. 7SASECOI•II3 U{4TT` �[I'YES SECOPID STORY ❑yES . DERYGADDEDT .';� HO ADDTr'rON3. NO An0X . ❑YES 1F YEg,PROVIDE.COgYOT: -:: PLANth"RSNAME:. . AFMI ❑ NO PLAT-RWGAPPROVALLbTfElt . ignature below, I cer* to each ofthe following I am.the pro etty owner or autho` on tfie eery oon and the information I haveprvrsc6ecave read a I)escnptcon of Wok andesandslatelamsrelgconstruotoee of e1pplTcant/Agent s� } Date CITY OF CUPERTINO - ' l Ti'.IP F.QTTM A TnR — RI TII .IIING DIVTSION imADDRESS: 20975 VALLEY GREEN DR # 209 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 Duplex Suppl. PC Fee: Q Reg. 0 OT PENTAMATION 1 RMAP 1 USE: $0.00 PERMIT TYPE: WORK AND DRYER HOOK UPS [REWWASHER. SCOPE Permit Fee: Mech. Plan Check 0.0 I.hrs $0.00 Plumb. Plun Check Elec. Plan Check Mech. Permit Fee:. IMPERMITPlrrmb. Permit Fee: Elec•. Permit Fee: Other Mech. ET Insp. 0.0 hrs $45.00 Other Plumb Insp. Other Elec. Insp. 0 1 11ech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (Le. manning, ruotic works, rue, aanuary,3ewer u1strict, acnoui District eta . These fees are based on the DrelinWha information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # $134.00 Mechanical IBAPPLOT7 Other Appliance/Equip Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. Q OT F0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 Construction :Tax: Administrative Fee: IADMIN $42.00 E) Work Without Permit? ® Yes ( No $0.00 Advanced Planning Free: $0.00 Select a Non -Residential Building or Structure E) i Travel Documentation Fee: ITRAVDOC $45.00 Strong; Motion Fee:. IBSEISMICR $0.50 Select an Administrative Item Bldg, Stds Commission Fee: 1BCBSC $1.00 a_r $133.50 $134.00 ....;,' tY.S4 $267.50 �• Revised: 04/01/2013 CUPERTINO 0VVNER=B 1 DER DISCLOSURE FORK t CONAMUNI T Y DEVELOPA4,ENT DEP'`-'•RTWi=N1 T ° BUiLDItw Ci` ]-"-ION 10300 TORR=,AVENUE - CU'PERTINO, CA 05014-325.5 (408) 777-3228 (408) 777-3333 Dear Property 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 ,P� q L G 1? APN I BP# C/, OWNER NArGRE orzr4 OWNER AD KESS !� �Oy do - DESCRIPTION OF WORK: Pit' % 1 4e 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 officlat address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNEWS ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 5-6. 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 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. ,S J2.1 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 responsibility: ,5 1/3. l understand as an "Owner -Builder" I am the responsible party. of record on the permit.. understand that. I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit.filed in his or her name instead of my own. 4.1 understand Contractors are required by to be licensed and bonded in Callfornia and to list their license numbers on permits and contracts. 5-LL9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal :Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. V10. 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. U 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. _W12. 1 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 unlicensed 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 Owrer-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 information.) 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 property owner's driver's license, form notarization, or other verification accepts to the city may required to be presence. d when the permit is issued to verify the property owner's signature Property Owner's Signature: 40, Date: '�/'AV- -- ---------=------ -- - -. -- - - The following Authorization Form is required to be completed by the property owr7er only when designating an agent of the property owner to' apply fora 'construction permit for the Owner -Builder). ;I AUTHORIZATION OF AGENT TO ACT. ON PROPERTY OWNER'S BEHALF Ex0 .-Ohgahe Notice to Properly. Owner, the &ecutlon of which i understand is my personal responsibility; Thereby authorize the following persons) to act as.my:agent(s) to apply for, sign, and file. the documents necessary to obtain an Owner Builder Permit for my project. Srnnriof Construction Project (or Description of Work): Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: .57 y' PERMIT # . Ott 00 OWNER'S NAME:/,/� �� /Qr1/ PHONE # t- '' 156 1 q P; GENERAL CONTRACTOR: ItAol W— QLU-j BUSINESS LICENSE # '`''260&e ADDRESS: CITY/ZIPCODE: C *Our municipal code requires all businesses working in the city to have a City of Cupertin6� 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: 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 s Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date