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10060045CITY OF CUPERTINO BUILDING PERMIT � BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 208 WNER'S NAME: KORET FOUNDATION OWNER'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 OWNER -BUILDER DECLARATION CON' CRACTOR: KORET PERMIT NO: 10060045 FOUNDATION 208-) 5 VALLEY GREEN DR DATE ISSUED: 06/09/2010 CUFERTINO, CA 95014 PHONE NO: r BUIL DING PERMIT INFO: BLDG ELECT PLUMB F_ 1 MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE APARTMENT BUIL DING Sq. I't Floor Area: Valuation: $100 6AP Number: 32609041.208 Occupancy Type: 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). VV4.757- 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 !ding construction, and hereby authorize representatives of this city to enter ,., 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. _ k t PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by Date: �* RE -ROOFS: All ; oofs shall be inspected prior to any roofing material being installed. If a roof is inst: Bled without first obtaining an inspection, I agree to remove all new materials for inspection. Sigi ature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I h::ve read the hazardous materials requirements under Chapter 6.95 of the Cal ifornia Health & Safety Code, Sections 25505, 25533, and 25534. I will ma ntain compliance with the Cupertino Municipal Code, Chapter 9.12 and the He dth & 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 wil l maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 255505, 25533, and 25534. Ov,ner or authorized agent. Date: 6 �i CONSTRUCTION LENDING AGENCY I h .reby affirm that there is a construction lending agency for the performance of we rk's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Le rider's Address ARCHITECT'S DECLARATION I i nderstand my plans shall be used as public records. Licensed Professional OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) T77-3228 - FAX (408) 777-3333 - buildir o @cupertino.org CUPERTINO i 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 OWNER NAME `I' DESCRIPTION OF WORK: OWNER ADDRESS 1 —2-0 \,(aN q 1,PJw J-( We are providing you with an Owner -Builder Acknowledgment 3.nd 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. inn 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 I11FORMATION (DIRECTIONS: Please read and initial each statement below t:) signify you understand or verify this information.) \ 0 I understand a frequent practice of unlicensed per: ons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the pi operty 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 property 2. 1 understand building permits are not required to b: signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor t) assume this responsibility. d on the at I �c1n 3. I understand as ant"O financial Ir risk eb1 hiring a ticer sed Contractorthe respc nsible party of randrhaving the permit t filed inch sdorhher may protect myself from potential Y name instead of my own. �4. 1 understand Contractors are required by law to belicensed and bonded in California and to list their license numbers on permits and contracts. �L5. 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 dollars ($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" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workors' 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. 4"n-7. I understand under California Contractors' State license Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent 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. _V�8. I understand as an Owner -Builder if I sell the pro )erty 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 . I understand I may obtain more information regarding my obligations as an "employer" from theInternaf Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also under:;tand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslt.ca.gov for more information about licensed contractors. �1/10. I am aware of and consent to an Owner -Builder buildi-ig permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -B►, ilders as well as employers. Vf12. 1 agree to notify the issuer of this form immediately 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'ticense 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 Contra,;tors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of thei - workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there (Sec 3097 Civ.) Lender Name: is a construction lending agency for the performance of the work for which this permit is issued 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. Dote: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency i:; required to be presented when the permit is issued to verify the property owner's signature. Signature of property owner: ` " �` Date: AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF (NOTE: The following Authorization Form is required to be comfileted by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). 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 f Dr, 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 c wner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: �� Date: L OwnerBuilderForm_2010.doc revised 04/12/10 CITY OF CUPERTINO 8 ITEMS OF 16 PERMIT RECEIPT OPERATOR: SylviaM COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609041.208 DATE ISSUED.......: 06/09/2010 RECEIPT #......... BS000010586 REFERENCE ID # .•• 10060045 SITE ADDRESS .....: 20975 VALLEY GREEN DR APT 208 SUBDIVISION ...... CITY CUPERZINO IMPACT AREA ...... OWNER KORET FOUNDATION ADDRESS 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUPERZINO, CA 95014 RECEIVED FROM ....: KAVITEA PENYALA CONTRACTOR .......: LIC # *OWNER* COMPANY KORET FOUNDATION ADDRESS 20875 VALLEY GREEN DR CITY/STATE/ZIP ...: CUP= INO, CA 95014 TELEPHONE ........ FEE ID UNIT QUANTITY AMOINT 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 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 ---------- :53.50 ---------- 0.00 ---------- 253.50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- CREDIT CARD 507.00 -------------------- A): --------------- TOTAL RECEIPT 507.00 CITY Of CUPEkTINO CITY OF CU13ERTINO GENERAL BUILDING PERMIT APPLICATION FORM 1 n(,\1 n mq APN # Date: Building A dress: 2C�--t'7� VA-ULEN Mailing Address (if different from building address): S A -M C -- Owner's Name: owner's Phone #: o moo© .2- HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Phone: T Contractor: B D Fax: Contractor License #: -T C3D Cupertino Business License #: ':ontact: M 1C1,VAC-"L 7-1210jt72 Phone: ��� _ 252—%6. q3 Fax: Residential NA Commercial F-1 Job Description: c1N1 `tel C�Ovn m C _C l W_ op A-pZ_TMEi,-'r c t 1 LD [ hL r Building Permit Info: Elect f Plu nb LIa Mech LJ BldgN6 Type of Construction (Usage Class): Occupancy Type: , I -A 1-B II/III/V-A El 11/111 B, IV -HT, V -B [✓� ❑ ' Valuation: �(�� Square Footage: Project Size: Express ❑ Standard V"' Large ❑ Major ❑ Preen 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: Fs -r help, contact Build it Green at www.builditgreen.or Revised 02/05/09