09090078 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR#456 CONTRACTOR:UBS PERMIT NO:09090078
OWNER'S NAME: UBS 20800 VALLEY GREEN DR DATE ISSUED:09/11/2009
IER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
JOB DESCRIPTION:INSTALL WASHER DRYER UNITS INSIDE
I hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions COMMERCIAL
Code and that my license is in full force and effect. APARTMENT BUILDINGS
1 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 Sq.Ft Floor Area: Valuation:$100
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:32609040.456 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
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 180 DAYS FROM LAST CALLED INSPECTION.
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. Issued by r � �~
Date:
Signature Date
Q� OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
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. 1 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
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or athho�r{ize agent.
become subject to the Worker's Compensation provisions of the Labor Code,I must n •�`�/_mc— ate:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
i nify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
SignatureDate
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32609040 .456
DATE ISSUED. . . . . . . : 09/11/2009
RECEIPT #. . . . . . . . . BS000008656
REFERENCE ID # 09090078
SITE ADDRESS 20800 VALLEY GREEN DR #456
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER UBS
ADDRESS 20800 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM UBS
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
----------------- --------------- --------------------
CASH 253 .50
---------------
TOTAL RECEIPT 253 .50
`1 CITY OF CUPERTINO
OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date:
Building Address: �y `� /
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0 b �C/ V,
Mailing Address (if different n building address):
fr7 �&_1L
Owner's Name: S Phone#:
U f2
HOA: (Exterior work only) Yes U Nog H o
If yes, provide letter from HOA
Contractor: Phone:
Te6 Fax:
Contractor License#: -T-)g 6
Cupertino Business License#:
Contact: ,�finn Phone: L4dg, 2_5-2_%q,3
/V'-c-L►a� � k Fax:
Residential Commercial
Job Description: 1,
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Building Permit Info:
Bldg V Elect 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 — z_
Valuation: Square Footage:
Project Size: Express ❑ Standard NTJr 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.org
Revised 02/05/09
W
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. A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
DC-Uc- ( b P_�C Yc Sk Uog u 1�9 (10Wc W(CA1_
S 10 C/- 9 5q S
R Dtti Mc--kDowS M5 0src _ r T 06q CTP_ICAL-
S S A N FiZA N OC-c > 0&: Z
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
326 CL 0760RO AVC— UMR>iNJ6
Rl SON�ILCC- CA
DOQALD KAIX aa65 WKL60a
Tacv,
................................................................................................................................
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:
A Date: 61
Job Address: o9WO6 VAL-LC-.Y �jkec-v, 45K 'LPC-�CTIN�, C' Permit#
61o
Any changes to the.information provided on this form shall be submitted to the City of Cupertino Build
Department.