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10090059 CITY OF CUPERTIP40 BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 492 CONTRACTOR:UBS PERMIT NO: 10090059 OWNER'S NAME: UBS 20800 VALLEY GREEN DR DATE ISSUED:09/09/2010 `ER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r License Class Lic.# MECH r RESIDENTIAL r- COMMERCIAL r Contractor Date JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9 APT (commencing with Section 7000)of Division 3 of the Business&Professions BLDGS 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 Sq.Ft Floor Area: Valuation:$100 permit is issued. APPLICANT CERTIFICATION APN Number:32609040.492 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued b Date:j�'._�d Signature Date to OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. 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 O n oranthorize aged /O Date: forthwith comply with such provisions or this permit shall be deemed rev CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating, for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save nnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address ,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. - I understand my plans shall be used as public records. Signature Date � I Licensed Professional CITY OF CUPERTINO 8 ITEMS OF 16 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32609040 .492 DATE ISSUED. . . . . . . : 09/09/2010 RECEIPT #. . . . . . . . . BS000011416 REFERENCE ID # 10090059 SITE ADDRESS 20800 VALLEY GREEN DR APT 492 SUBDIVISION . . . . . . . CITY CL PERTINO IMPACT AREA . . . . . . OWNER UES ADDRESS . . . . . . . . . . : 2C800 VALLEY GREEN DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM VILLAGES AT CUPERTI CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY UE,S ADDRESS 2( 800 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 1BPWATER UNIT 1. 00 42 .00 0 .00 42 . 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 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0. 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 253 .50 0 . 00 253 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 1.00 CHECK 253 .00 #2905 CHECK 253 . 00 #19959 --------------- TOTAL RECEIPT 507. 00 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO CA 95014-3255 (408)777-3228• FAX(408)777-3333 ia�cuoetnc.ora CUPERTINO 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: APN BP# SITE ADDRESSO JCIk�� % VD�(p v OWNER NAME OWNER ADDRESS ? DESCRIPTION OF WORK: 16 14 0Q We are providing you with an Owner-Builder Acknowledg Tient and s Information frmissued in your n Form to make you as the Owner-Builre der.ero We your responsibilities and possible risk you may incur by having permit will not issue a building permit until you have read,nd ca tedinitia! An agent oed your athe ownengannot exof each e to this noticenunless returned returned this form to us at our official you,the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 'W�1. 1 understand a frequent practice of unlicensej 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 fin M cihomeowneral risk ffor an inj uras a may sustained by an unlicensed person and his or her employees whil.,working on my property. Y 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 Contactor to assume this responsibility. 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 3 licensed Contractor and having the permit filed in his or her name instead of my own. �.I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. %�_5. 1 understand if I employ or otherwise engag a any persons, other than California licensed Contractors, and the total value of my construction is at least five hundrE d dollars($500), including labor and materials, I may be considered an employer' under state and federal 13w. YYV,�6. I understand if I am considered an"empl a'�workers'compensaton"under state and ral law, I must reistr with the state disability insuranceea d contribute t and federal government,withhold payroll taxes, p o unemployment compensation for each"employee.' I also understand my failure to abide by these laws may subject me to serious financial risk. W,r7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build themwith the intent to offer them for sa , does not exceed four within any(calendar yeaess all work ir, orall of thebwork licensed subcontractors and the number of structures is pe rmed under contract with a licensed general building Contractor. 8. 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. o�4"7rer•Builder•For•»z_1010.doc revised 04/14/10 9. 1 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 e Iso understand I may contact the California Contractors'State License Board (CSLB)at 1-800-321-CSLB (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. 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 Dwner-Builders as well as employers. 12. 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 a:,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 Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the states 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 agercy for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Ler der Address: Before a building permit can be issued,this form mist be completed and signed by the property owner and returned to the agency responsible for issuing the parmit. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the :ity may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE. The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction F ermit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution c f which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)t:)apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): 00 0 s Project Location or Address: TG r e e-121 r��G Name of Authorized Agent: T—Y'-1 Nev2 Tel No 40 2 — 7�`13 Address of Authorized Agent: V��S (`Cd Le�V 2-e v1 I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: b OwnerBuilderForm 2010.doc revised 04114/10 -1 CITY OF C;UPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPL[CATION FORM APN# 4 AD — � l C) Building Address' �-/ / -; 9 (50 el (7 e L A Mailing Address (if different fr building ad ress): rxn� L-4 Owner's Name: S Phone#: U f? HOA: (Exterior work only) Yes U No If`es, provide letter from HOA Contractor: Phone: Fax: Contractor License#: 'If 8� Cupertino Business License#: Contact: Phone: �c ►ue � `�v �� Fax: '4c>8-- c173- (02,5 Residential Commercial ❑ Job Description: Co �� rte,e✓G�cu. � �� Q.�-�i,��-� l��l� ��5 13uilding Permit Info: -/ Bldg Elect I Plumb [� Mech N3 Type of Construction (Usage Class): Occupancy Type: 1-B II/III/V-A II/III B, IV-HT, V-13 /4- 2- 1-A, ❑ ❑ Valuation: 00, Square Footage: Project Size: Express ❑ Standard Ell*' Large [] Major ❑ 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. fPoints Achieved: For help, contact Build it Green at www.builditgri,-en.or Revised 02/05/09