10030115 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 422 CONTRACTOR:UBS PERMIT NO: 10030115
OWNER'S NAME: UBS 20800 VALLEY GREEN DR DATE ISSUED:03/19/2010
WNER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# INSTAL WASHER/DRYER UNIT INSIDE BUILDING
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. 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 APN Number:32609040.422 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, G
costs,and expenses which may accrue against said City in consequence of the Issued I? ��_ r—�' Date:
granting of this permit. Additionally,the applicant understands and will comply y' --�
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 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.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: ' 'l Date:3 iJ 1
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 CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
ts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
anting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. _
Signature
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: SylviaM
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32609040 .422
DATE ISSUED. . . . . . . : 03/19/2010
RECEIPT # . . . . . . . . . BS000009985
REFERENCE ID # . . . : 10030115
SITE ADDRESS 20800 VALLEY GREEN DR APT 422
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER UBS
ADDRESS 20800 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM KAVITHA PENDYALA
CONTRACTOR LIC # *OWNER*
COMPANY UBS
ADDRESS 20800 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
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 253 . 50 0 . 00 253 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------
CREDIT CARD 253 .50 AX
---------------
TOTAL RECEIPT 253 . 50
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
A. All the work authorized by this permit
B. A portion of the work
C. _Z None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. All of the work
B. ✓ A portion of the work (complete section below)
Contractor Address/City. Phone# State License # Type of work to
L,...,..L.. ...]
qLAI--D, 1z eY UgtjqWql
hese C' Nqwalt
3. I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
erformed
1 v-evVp� 0 2�
..........................................................................................
I declare under penalty of perjury, that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Date: 3 0
Property Owner's Signature: ` -
Job Address: o�D�DC1 v `�� #W/ (?A Permit#
Cisoiy
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF CUPERTINO
CITY Of
CUPE(�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
1 b15
APN# Date:
Z -- C( - 0L1a , z.d 1
Building Address:
�2-6 ?C� �e �ce� �, Z
Mailing Address (if different fr building address):
7m�&--t
Owner's Name: 5 Phone#:
U e
HOA: (Exterior work only) Yes L_j No 14 d 2-cz-,->
If yes, provide letter from HOA
Contractor: Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Lt Phone:
Fax: L(c8-- 73- 1025-
Residential Commercial El
Job Description: 1'7
Building Permit Info:
Bldg tK Elect &r' Plumb Mech L�
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B A-2-
Valuation:
/0Q Square Footage:
Project Size: Express ❑ Standard NT"' 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.
oints Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 02/05/09