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10030045I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 267 CONTRACTOR: KORET FOUNDATION PERMIT NO: 10030045 OWNER'S NAME: KORET FOUNDATION ER'S PHONE: 4082530200 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor I hereby affirm that I am licensed under the provons 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. 20990 VALLEY GREEN DR APT 600 CUPERTINO, CA 95014 DATE ISSUED: 03/09/2010 PHONE NO: BUILDING PERMIT INFO: BLDG F ELECT r— PLUMB f— MECH r RESIDENTIAL COMMERCIAL F JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMMER'L APRTMENT BUILDINGS I have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Floor Area: 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. Signature—h,X—W —V ��, Dat _� L., OWNER -BUILDER DECLARATION I 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 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 -unify and keep harmless the City of Cupertino against liabilities, judgments, , 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. 1 Signature YLAI 6 bate �) V APN Number: 32609041.267 Valuation: $100 Occupancy Type: 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 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 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 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. O ner r aut ized ent• 1 Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 8 ITEMS OF 16 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609041.267 DATE ISSUED.......: 03/09/2010 RECEIPT 4.........: BS000009896 REFERENCE ID # ...: 10030045 SITE ADDRESS .....: 20975 VALLEY GREEN DR APT 267 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 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. 4/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. 7A portion of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to :;56 9?i - 9 - s a S o :;56 t jr 81'J - 4�3-o � w P-c.et-Ac wA S f+- to su 61 -IN DGS ,--$ 0 64 (e SS� G�it,�uSca 3. _ I will utilizeunlicensed 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 performed :;56 9?i - 9 - s a S o :;56 t jr 81'J - 4�3-o � I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner -Builder Information (reverse side). Property Owner's Signature: ` Date: �_ 1 ��y Job Address: Cy l�' it JX -1 ' ` L� i--- �, Permit # Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. 1 CITY OF CUPERTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # 09 O q 2, Date:©� Building Address: -7 VA( -6Y 2­�#aC Mailing Address (if different from building address): SSC Owner's Name:`. �, . �� - � p �� -T- �0N��� / Phone #: �� 2 S - HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Contractor: TB Q Phone: Fax: Contractor License #: -P 13D Cupertino Business License #: Contact: M i C ��+►4cL 7_12/0672 Phone: L106 252-76,113 Fax: 1408 - -17 3 -/02-5 Residential Commercial ❑ Job Description: STALL W f9 S WWPR YER UN / r S t_3'. `71 _TM Co vn rnl /-} iZi-mEr;i j3ti 1 C r Building Permit Info: Mech Bldg Ik Elect N� Plumb Ltd Type of Construction (Usage Class): Occupancy Type: — 2 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B [A"�„4--2- Valuation: /a4-? Square Footage: Valuation: Project Size: Express ❑ Standard L?"”' Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attacn it to the application or if applicable, include in plan set & the sheet index. _'oints Achieved: FL r help, contact Build it Green at www. Revised 02/05/09