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10030046 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20990 VALLEY GREEN DR APT 683 CONTRACTOR:KORET FOUNDATION PERMIT NO: 10030046 OWNER'S NAME: KORET FOUNDATION 20990 VALLEY GREEN DR APT 600 DATE ISSUED:03/09/2010 NER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONF BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH r RESIDENTIAL COMMERCIAL Contractor '/Vu6 i- Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL WASHER&DRYER UNITS INSIDE (commencing with Section 7000)of Division 3 of the Business&Professions COMMERCIAL APARTMENT BUILDINGS 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 Sq.Ft Floor Area: Valuation:$100 permit is issued. APPLICANT CERTIFICATION APN Number:32609053.683 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, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR 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. +� ,, Issued by: Date: Signature 1',�Y W �VLA_� Date 3 Li 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, Business&Professions Code) Signature of Applicant: Date: 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 Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. 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 become subject to the Worker's Compensation provisions of the Labor Code,I mustcaner or axthori,�ec�agent: forthwith comply with such provisions or this permit shall be deemed revoked. ,_-! J`L, -.u— Date: 10 CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's 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.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save mnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address .s,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 9.18. 1 understand my plans shall be used as public records. Signature &J, n✓ Date 3 Licensed Professional V CITY OF CUPERTINO 8 ITEMS OF 16 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32609053 . 683 DATE ISSUED. . . . . . . : 03/09/2010 RECEIPT #. . . . . . . . . BS000009896 REFERENCE ID # . . . : 10030046 SITE ADDRESS . . . . . : 20990 VALLEY GREEN DR APT 683 SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER KORET FOUNDATION ADDRESS 20990 VALLEY GREEN DR APT 600 CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : KAVITHA PENDYALA CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY KORET FOUNDATION ADDRESS 20990 VALLEY GREEN DR APT 600 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 507 . 00 AMEX --------------- TOTAL RECEIPT 507. 00 o CITY OF CUPERTINO COF CUPETRINO GENERAL BUILDING PERMIT APPLICATION FORM APN# Date. Building Address: �: G Vu LJ Mailing Address (if different from building addr ss): Owner's N e: Phone#: L4 HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Contractor: Phone: -T6 6 Fax: Contractor License#: -T 6 d Cupertino Business License#: ,` Phone: 4cs9- �.j,2�-7�,c/3Contact: .� . �� �✓� Fax: E-IaL X73 - jo ZS Residential Commercial El Job Description: n Af Building Permit Info: —/ Bldg Elect Plumb L�' Mech Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B F1 IUIIUV-A ❑ II/III B, IV-HT, V-B Valuation: Square Footage: loo, Project Size: Express ❑ Standard l2 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.buildit2reen.org 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 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 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 Cerfonnved ork to be Person/Firm Q-A { ................................................................ 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: l` G Permit Job Address: An char es to the.inf ormation Provided on this form shall be submitted to the CiM of Cu ertino Build Department.