10060130CITY OF CUPERTINO LUILDING PERMIT I
BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 503
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
Qj 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). _W
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
mnify and keep harmless the City of Cupertino against liabilities, judgments,
.s, 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. n A -1 \ t t
CON TRACTOR: KORET FOUNDATION PERMIT NO: 10060130
2087` VALLEY GREEN DR DATE ISSUED: 06/21/2010
CUP 3RTINO, CA 95014 PHONE NO:
BUI :.DING PERMIT INFO: BLDG ELECT r PLUMB r-
MECH r- RESIDENTIAL I— COMMERCIAL
JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMM'L
APR" MENT
BUII DINGS
Sq. 1't Floor Area:
APr Number: 32609041.503
Valuation: $100
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date: "C V
Issued by:
RE -ROOFS:
All -oofs shall be inspected prior to any roofing material being installed. If a roof is
inst riled without first obtaining an inspection, I agree to remove all new materials for
insl ection.
Sig': nature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I hive read the hazardous materials requirements under Chapter 6.95 of the
Ca ifornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
cot tpliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Ad litionally, should I use equipment or devices which emit hazardous air
con taminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
He tlth & Safety Code, Sections 25505, 25533, and 25534.
er or tho ' ed.a–f
�
Bate: (_�► �t
CONSTRUCTION LENDING AGENCY
I h ;reby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Le rider's Name
Le rider's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
2-11 1 V I Li sensed Professional
CITY OF CEPERTINO
7 ITEMS OF 7 PERMIT FECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 3260S041.503
DATE ISSUED.......: 06/21/2010
RECEIPT #.........: BSO00010671
REFERENCE ID # ...: 1006C130
SITE ADDRESS .....: 2097E VALLEY GREEN DR APT 503
SUBDIVISION ......
CITY CUPEF.TINO
IMPACT AREA ......
OWNER KORET FOUNDATION
ADDRESS ..........: 2087E VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPEF.TINO, CA 95014
RECEIVED FROM ....: VILLI.GES AT CUPERTI
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: KORET FOUNDATION
ADDRESS ..........: 2087E VALLEY GREEN DR
CITY/STATE/ZIP ...: CUPEF.TINO, 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
METHOD OF
PAYMENT
AMOUNT
REFERENCE
NUMBER
-----------------
CHECK
---------------
253.00
--------------------
4=2739
TOTAL RECEIPT
---------------
253.00
�I OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildirq@cupertino.org
CUPERTIN0 i
Dear Property Owner(s):
n submitted in your game listing yourself as the builder of the property
An application for a building permit has bee
improvements specified at:
SITE ADDRESS -5 � U..l(e_
OWNER NAME. 11 eg a.):' (
DESCRIPTION OF WORK: �Vl
t:.k 6o o
APN
OWNER ADDRE'iSY�x
�u��(� va-
BP#
al -76
oc, CO -
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 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 OF INFORMATION
(DIRECTIONS: Please read and initial each statement below t) signify you understand or verify this information.)
S 1. I understand a frequent practice of unlicensed per: ons is to have the property owner obtain an "Owner -
hat the pi operty owner is providing his or her own labor and material
Builder" building permit that erroneously implies t
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 property
\,—Al
2. 1 understand building permits are not required to b 3 signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor 0 assume this responsibility.
3. I understand as an "Owner -Builder" I am the respc nsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licersed Contractor and having the permit filed in his or her
name instead of my own.
1
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 )ersons, 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.
i ^)
"e
�+ 6. I understand if I am considered an mployer" under state and federal law, I must register with the state and
provide workers' compensation disability insurance, and contribute to
federal government, withhold payroll taxes,
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the it tent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures do�3s not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
n
V�J_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 subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFonn_2010.doc revised 04/12/10
CITY OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLIC�kTION FORM
00 �o�-Atglao
APN # `-)
Building Address:
OqT� VALW( 61rCr_ry
Mailing Address (if different from building address):
S /4-M C
Owner's Name:�,
� p �ti� 1 /fid-✓
Phone #:
�% 2 S 3--0L00
HOA: (Exterior work only) Yes ❑ No Z
If yes, provide letter from HOA
Contractor: TB D
Phone:
Fax:
Contractor License #: -r 130
Cupertino Business License #:
Contact: M i cl, -14CL-TT121W c72
Phone: 252 --76, q3
t
Fax: 1408 - -1-7 3 -/02-5
Residential Commercial
Job Description:
A),Sr/FLL W f9 S14&7, e)rDe f'E72 [J,v!
�' S l ° ' 471 C�r
C_O VY1 m
Building Permit Info:
Bldg [� Elect Rf Plum)
Mech
Type of Construction (Usage Class):
Occupancy Type:
1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B M
14--2—
4-2Va1-A,
Valuation:
luation: ��
Square Footage:
Project Size: Express ❑ Standard 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.builditgreen.or
Revised 02/05/09