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10100083I CITY OF CUPERTINO :BUILDING PERMIT I I BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 241 I CONTRACTOR: KORET FOUNDATION I PERMIT NO: 10100083 I OWNER'S NAME: KORET FOUNDATION 1ER'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. Date la 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 stricture 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). II/L'.1;y 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 nify and keep harmless the City of Cupertino against liabilities, judgments, , 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 J ntn" Date_ 208, 5 VALLEY GREEN DR I DATE ISSUED: 10/12/2010 CUI'ERTINO, CA 95014 PHONE NO: BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB r MECH F RESIDENTIAL F COMMERCIAL i JOI ; DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMMERCIAL APA EtTMENT BUILDINGS Sq. I't Floor Area: APT Number: 32609041.241 Valuation: $100 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issu :d by z __-- Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is insta led without first obtaining an inspection, I agree to remove all new materials for inspe ction. Sign ture of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I haN a read the hazardous materials requirements under Chapter 6.95 of the Cali] ornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain coml liance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air cont:.minants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Heal h & Safety Code, Sections 25505, 25533, and 25534. Own :r oorr author' ed agel A -� d' . " 7(( s' Date: 6l CONSTRUCTION LENDING AGENCY I here by affirm that there is a construction lending agency for the performance of work's for w iich this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I and :rstand my plans shall be used as public records. Licer sed Professional �:� ITY OF CUP ERTINO OWNER -BUILDER DISGLOSWRE FORK[ �i ��.. .-'� �' M'..fA ` %�-Jk+,:T+- e cupERrINa 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: SITE ADDRESS aO S vIALLCY e- APN BP# OWNER NAME, OWNER ADDRESS /4 Lie r2Lz-&w D� DESCRIPTION OF WORK: JW 5 T -A I -L W/o /f plC va35 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, initialei 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 permit ing authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF II\ FORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) :� 1. I 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 or her employees while work ng 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. %�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 responsibility. W4: 3. I understand as an "Owner -Builder' I am the respor sible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her n�Ta, stead of my own. . understand Contractors are required by law to be icensed and bonded in California and to list their license numbe s on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollar3 ($500), including labor and materials, I may be considered an "employer" under state and federal law. J 6. 1 understand if I am considered an "employer" unde- state and federal law, I must register with the state and federal government, withhold payroll taxes, provide worker,' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also u-iderstand my failure to abide by these laws may subject me too serious financial risk. \,� 'I k 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 does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 'I understand as an Owner -Builder if I sell the prope ty 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. Oi4a7.erBuilde7-Fo7-1?i2010.doc revised 04/12/10 r M09. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Admiristration, 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.-slb.ca.gov for more information about licensed contractors. V 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am tparty legally a\n�d financial) responsible forproyp'�ossed construction activity at the following address: n / agree that, as the party legally and financially re: ponsible for this proposed construction activity, I will abide by a!'-,--licable laws and requirements that govern Owner -Builders as well as employers. r 2. 1 agree to notify the issuer of this form immediatel,r of any additions, deletions, or changes to any of the infor -- ^n I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you c(n::ict with someone who does not have a license, the Contractors' Mate License Board may be unable to assist with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Cont .7t rs may be in civil court. It is also important for you to understand that if an unlicensed Contractor or emp' of that individual or firm is injured while working ,)n your property, you may be held liable for damages. If you cb,uin a permit as Owner -Builder and wish to hire Con:ractors, you will, be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRIY � 10N LENDING AGENCY (DIRECT': `: Please complete the following construction len Jing agency information.) I hereby : ` that there is a construction lending agency for :he performance of the work for which this permit is issued (Sec 309 ,. ) Lender N :m Lender Address: Before c. Jng permit can be issued, this form must be-ompleted and signed by the property owner and returned to he agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form no' -7. or other verification acceptable to the agency is required to be presented when the permit is issued to verify the ?rfv owner's sionature. SignaturF cf 7operty owner: Date: !OT/ (- /0 AUTHOE _. CIJ OF AGENT TO ACT ON PROPERTY OWMER'S BEHALF (NOTE: .;owing Authorization Form is required to be completed by the property owner only when designating an agent of . , ; :arty owner to apply for a construction permit f)r the Owner -Builder). Excluding ':otice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize )flowing person(s) to act as my agent(s) to appy for, sign, and file the documents necessary to obtain an Owner -P- Permit for my project. Scopec- isn Project (or Description of Work): 5TY}-L LJ10 Up -S; Project I Address: (�D11-e C YeetiJ L) 2. -ZW Name of _. Ind Agent: i1 C, f- W Tel No -r/16 Address`c-ized Agent: 20875 V /+ (I r -e e c� t � I declare alty of perjury that I am the property owner 'or the address listed above and I personally filled out the above in` ;nd certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verificatiL. ,_4able to the agency is required to be presented when the permit is issued to verify the property owner's signaturr,. N��A Property r n '-ignature:Date: I ` Oi4,n.erBuilderFor)??2010.doc revised 04/12/10 CITY Of CUPEkTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # Z� 0 Date: t D Building Address:` Cq 7. 6 VA -I. LEY &rCie.. n1 0 2 f^ �� I Mailing Address (if different from building address): S A -M C Owner's Name: . �� � p � 1=00,V"047-1 Phone #: Cf 2 S 3 --0Z0© HOA: (Exterior work only) Yes ❑ No Z If yes, provide letter from HOA Contractor: -T-H- Phone: Fax: Contractor License #: "T 13D Cupertino Business License #: Contact: MIC. +461 Phone: �0 , oc Fax: 1406- -173 -/02--S Residential U Commercial ❑ Job Description: C� im m G -W p1 #1+j-- %q p 0-lz-TYrE-NT j3Q I LD C ht s` Building Permit Info: A6/- Fr Bldg LvJ Elect Nf Plum) Mech Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B g ,,4--2- Valuation: Valuation: �� Square Footage: Project Size: Express ❑ Standard LJ"**' Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, inclade in plan set & the sheet index. Points Achieved: F,r help, contact Build it Green at www.builditreen.or Revised 02/05/09