10070103. CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20875 VALLEY GREEN DR APT 19
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.
Date
L7 OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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).?jvl/1 r—
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
•nnify 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. —7 /
Signature_ `� V Date / //1/
CONTRACTOR: KORET FOUNDATION PERMIT NO: 10070103
20875 VALLEY GREEN DR DATE ISSUED: 07/14/2010
CUPERTINO, CA 95014 PHONE NO:
BUILDING PERMIT INFO: BLDG r— ELECT PLUMB r
MECH r RESIDENTIAL r— COMMERCIAL
JOB DESCRIPTION: INSTALL WASHERIDRYER UNITS INSIDE COMM'L APT
BLDGS
Sq. Ft Floor Area: I Valuation: $100
APN Number: 32609064.19 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 D YS FROM LAST CALLED INSPECTION.
Issued by: Date:
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 authorised ag t: I
nA i �/ ��J�" Date: (/ I
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
7 ITEMS OF 35 PERMIP RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: B1{: Lot:
APN ........: 32509064.19
DATE ISSUED.......: 07/14/2010
RECEIPT #.........: BS300010868
REFERENCE ID # ...: 10370103
SITE ADDRESS .....: 20875 VALLEY GREEN DR APT 19
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER ............: KORET FOUNDATION
ADDRESS 20875 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
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
1
CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # � � � _ �, Date:
_
Building Address:
7S
o9
Mailing Address (if different from buildind address):
C:i e
Owner's Nar---
koi,r4, FVJ;.1.�c�'1��`6'kA
Phone #:
^�
/may
�� ,
Y U 7`S 020C>
HOA: (Exterior work only) Yes U No [%
If yes, provide letter from HOA
Contractor: � �
J
Phone:
Fax:
Contractor License #:
Cupertino Business License #:
Contact:
Phone: 9 0 - 2-52-76q-3
Fax: Li v? e?7 3- jC�2 S
Residential Commercial ❑
Job Description:
Building Permit Info:
/ /
Bldg M' Elect L� Plumb L�� Mech Lid'
Type of Construction (Usage Class):
Occupancy Type:
1-A, I -B ❑ II/III/V-A ❑ II/III B, IV -HT, V -E V
Valuation: oc Square Footage:
Project Size: Express ❑ Standard [2 LargeEl 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.builditgre�m.or
Revised 02/05/09
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPAR FMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 •
Dear Property Owner(s):
An application for a building permit has been submitted in dour name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESSA n?s ; r
OWNER NAME
DESCRIPTION OF WORK:
NOW
OWNER ADUKroc
e_6 Y1, C A,
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✓ing 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.)
a1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder' building permit that erroneously implies that tr e 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 niorking 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 prop,:rty.
\.,�_2. 1 understand building permits are not required o be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
Id 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 licensed Contractor and having the permit filed in his or her
name instead of my own.
�J 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 any 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.
_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 also understand my failure to abide by these laws may subject
me to serious financial risk.
VQ 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with th,: 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.
"V� 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 sut sequent owner(s) that result from any latent construction
defects in the workmanship or materials.
0ivnerBuilderF6r171 2010.doc revised 04/14/10
j-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 also 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.
�S 10. 1 am aware of and consent to an Owner -Build .r building permit applied for in my name, and understand that 1
am the party legally and financially responsible for proposed construction activity at the site address listed above.
l� 11. 1 agree that, as the party legally and financiall I responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
�
12. 1 agree to notify the issuer of this form immed ately 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 licen!;e, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as 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 status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following constructioir 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: Lendor Address:
Before a building permit can be issued, this form mus-: 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 city may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date:
NOTE : folo-------- - --------------------------------- ------------------------------------------------------------------------
The
----------------------------------------------
Thewing Authorization Form is required to bo 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 filo 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.
Property Owner's Signature: Date: Wiwi
ON,nerBuilderFaa•m 2010.doc revised 04/14/10