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10100204I CITY OF CUPERTINO BUILDING PERMIT I I BUILDING ADDRESS: 20875 VALLEY GREEN DR # 104 I CONTRACTOR: KORET FOUNDATION I PERMIT NO: 10100204 I I OWNER'S NAME: KORET FOUNDATION 12( 875 VALLEY GREEN DR I DATE ISSUED: 10/28/2010 I 'NER'S PHONE: 4082530200 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # 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. 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. APPLICANT CERTIFICATION 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 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 non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I 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. 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 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 - ' 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 ^aemnify and keep harmless the City of Cupertino against liabilities, judgments, , and expenses which may accrue against said City in consequence of the g.,.nting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. bo Signature rvt��Date (o Z CI )PERTINO, CA 95014 PHONE NO: JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL I vSTALL WASHER/DRYER UNITS INSIDE COMMERCIAL APARTMENT BUILDING Sc. Ft Floor Area: Valuation: $100 Al'N Number: 32609064.104 I Occupancy Type: I PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Is sued by: ����Date: /Q RE -ROOFS: Al I roofs shall be inspected prior to any roofing material being installed. If a roof is in: talled without first obtaining an inspection, I agree to remove all new materials for in: pection. Si;;nature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I I ave read the hazardous materials requirements under Chapter 6.95 of the Cf lifornia Health & Safety Code, Sections 25505, 25533, and 25534. I will m::intain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ht alth & Safety Code, Section 25532(a) should I store or handle hazardous m:aerial. Additionally, should I use equipment or devices which emit hazardous ah contaminants as defined by the Bay Area Air Quality Management District I wi II maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and th,� Health & Safety Code, Sections 25505, 25533, ►cL25534. Owner or authorized agent: " IV lt4 /"Date: CONSTRUCTION LENDING AGENCY I h,-reby affirm that there is a construction lending agency for the performance of we rk's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I u iderstand my plans shall be used as public records. Li<ensed CITY OF CUPERTINO 1 ' I FFF FCTTwrATnR - BUILDING DIVISION La 1 1JL s s ADDRESS: DATE: REVIEWED BY: Mech. Permit Fee: IMPERMIT APN: BP#: *VALUATION: $100 *PERMIT TYPE: Building Permit PLAN CIAECK TYPE: Alteration / Repair PRIMARY USE: Multi -Family Dwelling Buildina is >3 Stories 0 Yes No PENTAMATION 1 RPDP PERMIT TYPE: WORK $0.00 SCOPE 1I1/1TT- TI_ __ _ CCJ a-. ._ .. Lu.....J ,.....L,.., --I.....:.,,..,, :.,f,.s.,,.�;,,., ,,,,.,at, trio „»d are anly an estimate. Contact the Dept for addn'l info. IVVIA (nese re aseu on use FEE ITEMS (ree Resolution 09-051 Ej'. '/1:701 Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Check I C.0C.0j hrs $0.00 Elec. Plan Check 0.0 1 hrs $0.00 Mech. Permit Fee: IMPERMIT Plumb. Permit Fee: IPPERMIT Elec. Permit Fee: IEPERMIT Other Mech. Insp. 0.0 hrs $42.00 Other Plumb Insp. C . 0 hrs $42.00 Other Elec. Insp. 0.0 hrs $42.00lnv, h, j 11`1x,P, /"-C, 1,co 1I1/1TT- TI_ __ _ CCJ a-. ._ .. Lu.....J ,.....L,.., --I.....:.,,..,, :.,f,.s.,,.�;,,., ,,,,.,at, trio „»d are anly an estimate. Contact the Dept for addn'l info. IVVIA (nese re aseu on use FEE ITEMS (ree Resolution 09-051 Ej'. '/1:701 FEE QTY/FEE ---- MISC ITEMS Plan Check Fee: $0.00 =# $42.00 Plumbing 1PREPPIPE Piping, Floor Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 PME Plan Check: $0.00 $42.00 Electrical 1BREMRECEP Recep/Switch/Outlets Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT 0.0 1 hrs $0.00 $0.00 = # Mechanical $0.00 1MFR=<100 Furnace, Forced -Air PME Unit Fee: PME Permit Fee: $126.00 Acoustical Fee: 0 Yes E) No $0.00 0 E) Work Without Permit? 0 Yes E) No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure E) Travel Documentation Fee: 1 TRA VDOC $42.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $169.50 $84.00 TOTAL FEE: $253.50 Revised: 10/17/2010 CITY OF CUPERTINO 8 ITEMS OF 16 PERMIT RE2EIPT OPERATOR: SylviaM COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609064.104 DATE ISSUED.......: 10/28/2010 RECEIPT #......... BS000011865 REFERENCE ID # ...: 10100204 SITE ADDRESS 20875 VALLEY GREEN DR # 104 SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER KORET FOUNDATION ADDRESS 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: VILLACES AT CUPERTI CONTRACTOR LIC # *OWNER* COMPANY KORET FOUNDATION ADDRESS 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 TELEPHONE ......... FEE ID UNIT QUANTITY AMOUNT PD -TO -DT ---------- THIS REC ---------- NEW BAL ---------- ---------- 1BCBSC ------------- VALUATION ---------- 100.00 ---------- 1.00 0.00 1.00 0.00 1BREMRECEP NO. OUTLETS 1.00 42.00 0.00 42.00 0.00 1BSEISMICR VALUATION 100.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1MPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PREPPIPE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 ---------- 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 253.50 0.00 253.50 0.00 CUPERTINO OWNER -BUILDER DISCL0;3URE FORM COMMUNITY DEVELOPMENT DEPARTME JT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • build nand cupertino.orq Dear 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: SITEDRESS�, APS BP# .L0 %j75 V 4 L t o- G�wv/C OC�o6v-, o e_l SMEOWNER ADDRE SS 0►26T r-0UR1 f)A Tt0P 1 2 0f375 U r+LCe e 6 va0 DESCRIPTION OF WORK: o \ n v Jo S 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 official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF DIFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) fYv'I understand a frequent practice of unlicensed perspns 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 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. IWA& I 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 tc assume this responsibility. I understand as an "Owner -Builder' I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licenEed Contractor and having the permit filed in his or her name instead of my own. t 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. J�A. 1 understand if I employ or otherwise engage any p arsons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer' under state and federal law. ?dAj6. I understand if I am considered an "employer" undE r state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also L nderstand my failure to abide by these laws may subject me to serious financial risk. 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures doeE not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 1� I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. UvnerBuilderForrn 2010.doc revised 04/14/10 i 9. 1 understand I may obtain more information regardirg 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.rslb.ca.gov for more information about licensed contractors. 0. 1 am aware of and consent to an Owner -Builder bL ilding permit applied for in my name, and understand that I am 'he party legally and financially responsible for propose] construction activity at the site address listed above. t 1. 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. `� 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the info mation I have provided on this form. Licensed contractors are regulated;by laws designed to protect the public. If YOU ,ontract with someone who does not have a license, the Contractors' State License Board may be unable to ass :,,t you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Cc: ti-.ictors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or erce of that individual or firm is injured while working )n your property, Xou may be held liable for damages. If yoL. �l 'j,n a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not tho Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONS i:(1CTION LENDING AGENCY (DIRE JNS: Please complete the following construction len ling agency information.) herel , :,( imi that there is a construction lending agency for the performance of the work for which this permit is issued (Sec C v.) Lender .�jme: Lender Address: Befor ding permit can be issued, this form must be completed and signed by the property owner and return : to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form t- --i'ion, or other verification acceptable to the city maybe required to he presented when the permit is issued to vera property owner's signature. Prope, , , tier's Signature: Date: ------------------------------------------------------------------ ------ P---- ----------- ------------------------ (NOT: `ollowing Authorization Form is — m required to be coleted b-- p the property owner onlywhen designating an agent ,)roperty owner to apply for a construction permit `or the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluc, ; ;ike Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby author , the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Ownc ` ;r Permit for my project. I,J b `%ooi.< () to Scope Struction Project (or Description of Work): Projec' ion or Address: 20 v YS 1f Gc ie 6 V �-� l Name horized Agent: i'11 l i.tAA&L T V-Z/uC_►2 Tel No L/D e AddrF ,thorized Agent: 2 v 0 7-5 lJ �c i e,- 6V e e� Dl- '� 7 I decL. u;cier penalty of perjury that I am the property owne- for the address listed above and I personally filled out the above � roetion and certify its accuracy. Note: A copy of tho property owner'sdriver's license, form notarization, or other verific. :,-ceptable to the city maybe required to be presE nted when the permit is issued to verify the property owner's signal! Prope, C,,r,ner's Signature: I L2�`X�c�-�` �'' "�J� Date: Ownel'BuilderForin 2010.doc revised 04/14/10 a CITY OF CUPEkT1NO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM i6in6a-01V APN # _ 30,6 Date: /0 Building Address: _ SI D `t �. 7;5 VAILLEY Cir C t ry 1) 2 Mailing Address (if different from building address): 5 A -M r - Owner's Name: J:�© je-G- T Phone #: HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Contractor: TB 1) p Phone: N�fV-py\-< PA Fax: Contractor License #: -T13D Cupertino Business License #: Contact: (yl i r+61TY2/AR12 ClA. Phone: q©6 - � 52-76 �3 Fax: 1406- 173 -/02-6 Residential NJ Commercial ❑ Job Description: Building Permit Info: 6 � Bldg Elect 9f Plumb Mech Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B [V r Valuation: ��v Square Footage: Project Size: Express ❑ Standard tom' Large ❑ Major ❑ ,- Green Building: Please complete relevant portion of th z Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. .'oints Achieved: FLr help, contact Build it Green at www.builditgESen.o r Revised 02/05/09