10090058 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20990 VALLEY GREEN DR APT 615 CONTRACTOR:KORET FOUNDATION PERMIT NO: 10090058
OWNER'S NAME: KORET FOUNDATION :0875 VALLEY GREEN DR DATE ISSUED:09/09/2010
ER'S PHONE: 4082530200 4-UPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION 'WILDING PERMIT INFO: BLDG F_ ELECT[_ PLUMB r
License Class Lie.# MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
IOB DESCRIPTION: INSTALL WASHER&DRYER UNITS INSIDE
I hereby affirm that I am licensed under the provisions of Chapter 9 COMMERCIAL APT
(commencing with Section 7000)of Division 3 of the Business&Professions 3UILDINGS
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:32609053.615 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 �l
9.18. Issued by: =-? Date: ( `�
Signature Date
Qp 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, Date:
Business&Professions Code) Signature of Applicant:
I,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 Wv;�_
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for 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 Owner or authorized a ent:
become subject to the Worker's Compensation provisions of the Labor Code,I must —Date: 1
forthwith comply with such provisions or this permit shall be deemed revoked. �-
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
-mify 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 I understand my plans shall be used as public records.
9.18.
Signature �r_lj
Date Licensed Professional
CITY OF CUPERTINO
8 ITEMS OF 16 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: B1}--: Lot:
APN . . . . . . . . : 32609053 .615
DATE ISSUED. . . . . . . : 09,'09/2010
RECEIPT #. . . . . . . • • : BS000011416
REFERENCE ID # . . . : 10090058
SITE ADDRESS . . . . . : 20'390 VALLEY GREEN DR APT 615
SUBDIVISION . . . . . . .
CITY CU?ERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KO:ZET FOUNDATION
ADDRESS 20375 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM VILLAGES 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
1PRREPIPE NO OF FIXTURE 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
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
(408)777-3228- FAX(408)777-3333-_,uiidino(a�)cjoertinc.orc
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:
SITE ADDRESS Vu e ee rt lD r APN BP#
—o � --bt5
OWNER NAME OWNER AC DRESS
DESCRIPTION OF WORK: IJ ST - L b "� U v 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 ha ring 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 INFORMATION
(DIRECTIONS:Please read and initial each statement bel)w to signify you understand or verify this information.)
MA1. 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 dvorking 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
W2.insurce coverage for injuries to workers on my property.
1 understand building permits are not required to be signed by property owners unless they are responsible for
Whhenstruction and are not hiring a licensed Contractor to assume this responsibility.
. 1 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 licensed Contractor and having the permit filed in his or her
name instead of my own.
Vf4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numb rs on permits and contracts.
5. 1 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 lollars ($500), including labor and materials, I may be
ol
ered an "employer' under state and federal law.. I understand if I am considered an"employer' under state and federal law, I must register with the state and government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
`nmte to serious financial risk.
�1V1� 7 I understand under California Contractors' StE to License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with tF a 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 pe rmed under contract with a licensed general building Contractor.
8. I understand as an Owner-Builder if I sell the )roperty for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any suosequent owner(s)that result from any latent construction
defects in the workmanship or materials.
DianerBuilderForm 2010.doc revised 04/14/10
v�9. 1 understand I may obtain more information retarding my obligations as an "employer"from the Internal
Revenue Service,the United States Small Business Mministration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I alE o understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or vrww.cslb.ca.gov for more information about licensed
contractors.
_M44710. 1 am aware of and consent to an Owner-Built er 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. I agree that, as the party legally and financialy responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Cwner-Builders as well as employers.
►Y44'' 12. 1 agree to notify the issuer of this form immec iately 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 licerse, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as 3 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 wot king on your property,you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to him Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the statu3 of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following constructic n 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 mu A 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 acceptable to the c ity may be required to be presented when the permit is issued
to verify the property owner's si nature.
Property Owner's Signature: Date:
------------------------------ ---------------------------------------------------------------------- - -- -- ---- - -- - - ----- -
(NOTE: The following Authorization Form is required to 5e completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to 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):
Project Location or Address: `Z U �1y Pr"c ,? 6(r{e,-. 0 n'
Name of Authorized Agent: M t� �k✓a-l%1- �✓Z
i n!e/L Tel No '-1 U�,— 3
Address of Authorized Agent:
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: WLfl,_Ck-k� r4 Date: to —
OwnerBuilderForm_2010.doc revised 04/14110
C ITY OF CUPERTINO
CUPE�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date-
Building Address: /'
2.O D V u de e->✓e e�
Mailing Address (if different from building addr ss):
c c,�
Owner's Nre. L �/(/� Phone#: J�j�► zoo j
HOA: (Exterior work only) Yes ❑ No _
If yes, provide letter from HOA
Contractor: Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone: i f cs9_ �9_57.2-74413
Fax: f-I a L `�7 3 10 ZS
Residential Commercial ❑
Job Description: -
Uj6__SL2_1' 4. foe�e_l-
Ile
Building Permit Info:
Bldg Elect LAS Plumb Lid' Mech
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/IIUV-A ❑ IUIII B, IVH
T V-B 14 —
Valuation: Square Footage:
Project Size: Express ❑ Standard [2 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.
IPoints Achieved: .
For help, contact Build it Green at www.builditreen.or
Revised 02/05/09