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10070102CITY OF CUPERTII BUILDING ADDRESS: 20875 VALLEY GREEN DR APT 21 OWNER'S NAME: KORET FOUNDATION /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 bG 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 ;unify 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 I 1 l�'L J( _J (�i�( to A-kDateL� vO BUILDING PERMIT CONTRACTOR: KORET FOUNDATION I PERMIT NO: 10070102 20875 VALLEY GREEN DR 1 DATE ISSUED: 07/14/2010 CUPERTINO, CA 95014 PHONE NO: BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r MECH F RESIDENTIAL r COMMERCIAL F JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMM'L APT BLDGS Sq. Ft Floor Area: I Valuation: $100 APN Number: 32609064.21 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: �/ J�J'�i �Ci � )DQate: T RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance 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 contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or thor' r a G', I Dater V CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 7 ITEMS OF 35 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609064.21 DATE ISSUED.......: 07/14/2010 RECEIPT #.........: BS000010868 REFERENCE ID # ...: 10070102 SITE ADDRESS .....: 20875 VALLEY GREEN DR APT 21 SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: KCRET FOUNDATION ADDRESS ..........: 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM CONTRACTOR ... COMPANY ...... ADDRESS ...... CITY/STATE/ZIP TELEPHONE .... VILLAGES AT CUPERTI LIC # *OWNER* KCRET FOUNDATION 20875 VALLEY GREEN DR CUPERTINO, CA 95014 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 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 ---------- 253.00 ---------- 0.00 ---------- 253.00 ---------- 0.00 t0k- 01<--)a CITY OF CUPERTINO CITY OF CUPEi�TiNO GENERAL BUILDING PERMIT APPLICATION FORM APN # - , Cr -3Z _ a _ `f Date: Building Address: Mailing Address (if different from buildin address): (n L�- Owner's Nar--- - K0 ipre-+' F& J LA C44 i " CX -1 Phone #: HOA: (Exterior work only) Yes U No If yes, provide letter from HOA Contractor: � � Phone: Fax: Contractor License #: Cupertino Business License #: Contact: Phone: t-1 ng-_ 2�,52 7 q2 -rev Fax: Li CIS-- q *7 3 - 10 ZS" Residential Commercial ❑ Job Description: , !i i� bn e ✓ C. r .� C � �. i � IM- ew7 �J l ��` �� �-�- S , Building Permit Info: Bldg I' Elect Plumb Mech 12/ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B A7-21 Valuation: F 6)o Square Footage: Project Size: Express ❑ Standard [V"' 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. Points Achieved: For help, contact Build it Green at www.builditgreEsn.or Revised 02/05/09 CUPERTINO OWNER -BUILDER NOTIC�#E COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • .: �ii�i-a c a_e i� :)-c Effective January, 1, 2009, Assembly Bill '� 335 amends California Health and Safety Code, Section 19825, regarding disclosures and verij ications required for all applicants seeking Owner - Builder construction pen -nits. These new app.ication requirements provide an enhanced level of consumer awareness and protection for property owners accepting the risks associated with Owner -Builder construction permits. "The Legislature hereby finds and declares th,-_t there is an urgent and statewide public interest in assuring that building contractors comply witl: the Contractors License Law ... and provisions of law relating to Workers' Compensation Insura -ice for building construction, that property owners are informed about, and protected from, fraudlilent representations, liability for worker's injuries, liability for material and labor costs unpaid by contractors, licensing requirements, and employer's tax liabilities when improving thei • property as owner -builders" Important information you need 0 know BEFORE pulling your permit! The term "Owner -Builder" can mean three different things: "Owner as Worker", "Owner as Contractor" or "Owner as Employer" Understand each has Benefits or Fisk, and it is possible to combine them! Hiring a California Licensed Contractor means you do not personally perform any of the construction work, the pen -nit is not taken out in your name, you are not personally responsible for the construction and you are not an Owner -Builder. Instead, you become a "Customer" ai.d California law provides you the benefit of protection from poor workmanship, failure to finish the job and financi Ll risk due to worker injury. Benefit/Risk: Highest Bent fits and the Least amount of Risk Owner -as -Worker is a type of Owner -Builder where you personally perform the construction work, the permit is taken out in your name and you are personally responsible for the construction management, knowledge, workmanship, and completion of the job. You benefit by not paying others to perform this work for you and your risk depends on your own ability to complete the job sL ccessfully. Benefit/Risk: with L ..; • != i 3 -, ; : 1 Ri s k Owner -as -Contractor is a type of Owner -Builder where you personally act as your own General Contractor, the permit is taken out in your name and you hire California licensed sub -contractors to perform portions of the construction work. WARNING: The benefit of protection provided by law when you hire only California licensed sub -contractors can tum to serious financial risk if you hire unlicensed contractors to perform any of the work. Benefit/Risk: and Significant Financial Risk Owner -as -Employer is a type of Owner -Builder whe -e you pay any individual to perform any construction work valued at more than $500.00, the permit is taken our in your name and you are personally responsible for their employment requirements, supervision, performance, safety and welfare while on your property. WARNING: Cost savings benefit can turn to serious financial risk if you fail to deduct payroll taxes or provide 1410rkers compensation insurance for each worker. Benefit/Risk: with 'Si<<nificant Financia[ Risk Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects and include workmanship and workers' compensation issues Homeowners suffer financial harm due to defective workmanship and injured employees. OivnerBuilder 2010.doc revised 06/08/10 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • D -Z 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 0 Vo 1 e e" AK w 21ck-1-ivw APN BP# OWNER NAM QQWNER ADDRESS 'J0 DESCRIPTION OF WORK: We are providing you with an Owner -Builder Acknowledgrrent 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 CIF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) V91. 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. 1, 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 proporty. 42. 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 Contract)r to assume this responsibility. _3. 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 li ,-ensed Contractor and having the permit filed in his or her name instead of my own. V_C 4. 1 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 engage a iy persons, other than California licensed Contractors, and the total value of my construction is at least five hundred collars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 1l`�'(6. 1 understand if I am considered an "employer" ender 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 a so understand 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 tho intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures Joes not exceed four within any calendar year, or all of the work is performed under contract with a licensed general bL ilding Contractor. 8. 1 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 sutsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderFol"n1 2010.doc revised 04/14/10 1-99. 1 understand I may obtain more information rec arding my obligationsias 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 alc o understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or viww.cslb.ca.gov for more information about licensed contractors. U� 10. 1 am aware of and consent to an Owner-Builcer building permit applied for in my name, and understand that amtheparry legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financial y responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. \S 12. 1 agree to notify the issuer of this form immeciately of any additions; deletions, or changes to any of the information I have provided on this form. Licensed cor tractors are regulated) by laws designed to protect the public. If you contract with someone who does not have a licen 3e, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint.i 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 worcing 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 status: of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following constructio 7 lending agency information.) I hereby affirm that there is a construction lending agencci 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 acceptable to the ci!y may be required to he 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 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: Name of Authorized Agent: Address of Authorized Agent: Tel No 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. l Property Owner's Signature: 7� Gate: t D OwnerBuilderForni 2010.doc revised 04/14/10