10030130 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 406
CONTRACTOR:UBS PERMIT NO: 10030130
OWNER'S NAME: UBS
20800 VALLEY GREEN DR DATE ISSUED:03/22/2010
.1ER'S PHONE: 4082530200
CUPERTINO,CA 95014 1 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r- ELECT r- PLUMB
License Class Lic.# MECH r- RESIDENTIAL r- COMMERCIAL
Contractor Date
.TOB DESCRIPTION:INSTALL WASHER/DRYER UNITS INSIDE COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$100
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued.
APPLICANT CERTIFICATION APN Number:32609040.APT406 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
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
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Date:
Issued by:
Signature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
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). 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
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I caner or uthon d agen
become subject to the Worker's Compensation provisions of the Labor Code,I must I'm ^ 1 c n � ,Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
ove information is I hereby affirm that there is a construction lending agency for the performance of works
I certify that I have read this application and state that the ab
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
r Lender's Name
to building construction,and hereby authorize representatives of this city to ente
unnn the above mentioned property for inspection purposes.(We)agree to save
lnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
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.
Signature ��/1.1�- hate 3 ��- 2 0 Licensed Professional C
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32609040 .APT406
DATE ISSUED. . . . . . . : 03/22/2010
RECEIPT #. . . . . . . . . BS000009998
REFERENCE ID # 10030130
SITE ADDRESS 20800 VALLEY GREEN DR APT 406
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 AMEX
---------------
TOTAL RECEIPT 253 .50
s
1
CITY OF CUPERTINO
CUPEf�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date:
20 ( o
Building Address-ZO (W60
Vc, i
Mailing Address (if different frrei
building address):
U--
Owner's Name: S Phone#:
U ��
HOA: (Exterior work only) Yes U No
If yes, provide letter from HOA
Contractor: Phone:
T e 6 Fax:
Contractor License#:
Cupertino Business License#:
Contact: A-,je_ Phone: L4099- '2-5-2-76q3r �v �c-c� Fax: 408- 8173- 1025
Residential Commercial
Job Description:
Co LA-4 tAt e✓C-j l a�-�i vt e� 1 J dd
P
Building Permit Info:
Bldg tK Elect Plumb Nr' Mech L�
Type of Construction (Usage Class): Occupancy Type:
I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B 4- 7—
Valuation:
/ Square Footage:
Project Size: Express ❑ Standard [ /r 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:
For help, contact Build it Green at www.builditgreen.orsz
Revised 02/05/09
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, 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. 7 A portion of the work (complete section below)
Contractor Address/City Phone# State License # Type of work to
per :=e
4e
38 P�- 61 b 0
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.
Address/City Phone Number Type of work to be
Person/Firm performed
if. A
' 4�
ti
v�eg 5 U 0 - ��` C�
........................................................................
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:
Property Owner's Signature:
3]t y v
2ng0 U It- 0 c�1t.L� Permit# i u v
Job Address: ,
5 ui�
es to the.information rovided on this form shall be submitted to the Ci of Cu ertino Build
An char
Department.