10070104CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 275
CONTRACTOR: KORET FOUNDATION
PERMIT NO: 10070104
OWNER'S NAME: KORET FOUNDATION
20875 VALLEY GREEN DR
DATE ISSUED: 07/14/2010
NER'S PHONE: 4082530200
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
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MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMM'L 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.
Sq. Ft Floor Area:
Valuation: $100
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.
APN Number: 32609041.275
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
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
180 DAYS FRO LAST CALLED INSPECTION.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations the Cupertino Municipal Code, Section
G�
per
9.18.
Issued by: Date:
Signature Date
V OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
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,
Signature of Applicant: Date:
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code). ,V/09
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
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
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation Insurance, as provided for by
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
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued, I shall
Health & Safety Code, Sections 25505, 25533, and 25534.
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
�caner or akthorizgd agwi A
�1 Date:
become subject to the Worker's Compensation provisions of the Labor Code, I must
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forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
*mify 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
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.
Licensed Professional
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Signature Date V
CITY OF CUPERTINO
7 ITEMS OF 35 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32609041.275
DATE ISSUED.......: 07/14/2010
RECEIPT #.........: BS000010868
REFERENCE ID # ...: 10070104
SITE ADDRESS .....: 20975 VALLEY GREEN DR APT 275
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER ............: KCRET FOUNDATION
ADDRESS ..........: 20875 VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: VILLAGES AT CUPERTI
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: KCRET FOUNDATION
ADDRESS ..........: 2C875 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
CITY OF ICUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
3-2- o / 2- 7-:!1- 71 M10 -
Building Address:
75
'2 Oq 75 V A -L ICY 6Ir r' t A) 1) 2 X
Mailing Address (if different from building address):
5 A -M C-"
Owner's Name:
D 12�T- f=DCiit/1�/'i-i
Phone #:
--Ozoo
HOA: (Exterior work only) Yes ❑ No
If yes, provide letter from HOA
Contractor: -TB
D
Phone:
Fax:
Contractor License #: -T 13D
Cupertino Business License #:
Contact: M I C 4146 Tfe/W e72
Phone: q06 - 2-5;2-76- q3
Fax: 140 $ - 17 3 - /0 2-5
Residential NJ Commercial
Job Description:
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Building Permit Info:
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6 NJ
Bldg Elect [f Plumb Mech
Type of Construction (Usage Class):
Occupancy Type:
1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V-:3 H""
,4--2-
4—Val1-A,
uation: 10U Square Footage:
Valuation:
Project Size: Express ❑ Standard Lam' 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:
Fer help, contact Build it Green at www.builditgrE�en.or
Revised 02/05/09
CUPERTINO
OWNER -BUILDER DISC _OSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • 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 ,your name listing yourself as the builder of the property
improvements specified at:
SITE ADD SS APN
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OWNER NAMEOWNER
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DESCRIPTION OF WORK:
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We are providing you with an Owner -Builder Acknowledgrient 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 indicatod. 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 below to signify you understand or verify this information.)
V;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 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 proparty.
V 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 Contrac or to assume this responsibility.
-13. 1 understand as an "Owner -Builder" I am the rE!sponsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a I censed Contractor and having the permit filed in his or her
name instead of my own.
�4. I understand Contractors are required by law t) be licensed and bonded in California and to list their license
numbers on permits and contracts.
,. I understand if I employ or otherwise engage a ny persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law
v� 6. 1 understand if I am considered an "employer" under 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 E Iso understand my failure to abide by these laws may subject
me to serious financial risk.
,,�_7. 1 understand under California Contractors' Sta re License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with th3 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.
`
yI08. 1 understand as an Owner -Builder if I sell the f roperty 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.
OwnerBuilderForm 2010.doc revised 04114/10
V-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 als: 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.
10. 1 am aware of and consent to an Owner-Builcer building permit applied for in my name, and understand that
am the party legally and financially responsible for proposed construction activity at the site address listed above.
1� 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.
L12. 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 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 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 wor<ing 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 agenci 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 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: The following Authorization Form is required to t;e completed by the pr ___.____. - �- -n-____. n ---main_ - _ --
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:
rel 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:r��►
l
Oi+,nerBuilderForrrr 2010.doc revised 04/14/10