09110044CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20975 VALLEY GREEN DR #271
CONTRACTOR: KORET FOUNDATION
PERMIT NO: 09110044
OWNER'S NAME: KORET FOUNDATION
20990 VALLEY GREEN DR #600
DATE ISSUED: 11/09/2009
ER'S PHONE: 4082530200
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
MECH [_ RESIDENTIAL F COMMERCIAL
Contractor Date
JOB DESCRIPTION: INSTAL WASHER/DRYER UNITS INSIDE,
I hereby affirm that I am licensed under the provisions of Chapter 9
COMMERCIAL
(commencing with Section 7000) of Division 3 of the Business & Professions
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
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: 32609041.271 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
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
Signature Date
.[yI OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1 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:
1, 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)
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. I will maintain
the Cupertino Municipal Code, Chapter 9.12 and the Health &
performance of the work for which this permit is issued.
compliance with
Safety Code, Section 25532(a) should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District 1 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 auth ed a ent• ( O �I
Lc� abate:
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.
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
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.
` � b�
Date
Licensed Professional
Signature
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32609041.271
DATE ISSUED.......: 11/09/2009
RECEIPT #......... BS000009147
REFERENCE ID # 09110044
SITE ADDRESS 20975 VALLEY GREEN DR #271
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER KORET FOUNDATION
ADDRESS ..........: 20990 VALLEY GREEN DR #600
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: KORET
CONTRACTOR
.......:
LIC # *OWNER*
COMPANY ..........:
KORET FOUNDATION
ADDRESS ..........:
20990 VALLEY GREEN
DR #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
42.00
0.00
0.00
1BREMRECEP
NO. OUTLETS
1.00
42.00
0.00
0.00
0.50
0.00
1BSEISMICR
VALUATION
100.00
0.50
42.00
0.00
42.00
0.00
1EPERMITFE
FLAT RATE
1.00
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
1TRAVDOC
FLAT RATE
----------
-----42_00
------0.00
----------
253.50
0.00
253.50
0.00
TOTAL PERMIT
METHOD OF
PAYMENT
AMOUNT
REFERENCE NUMBER
--------------------
-----------------
CREDIT CARD
---------------
253.50
AMEX
TOTAL RECEIPT
---------------
253.50
0111
CITY OF CUPERTINO
CUPEk ANO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 3z6 -0q- Date: al �oa
Building Address: 20q
Mailing Address (if differe t from building addr ss): C�
Owner's Name:
HOA: (Exterior work /only) Yes U No
If yes, provide letter from HOA
Contractor:
,-I,-QD
Contractor License #: Te 0
Cupertino Business License #:
Contact:
Residential 9 Commercial
Phone #:
YOK-2S3- 0 2-0o
Phone:
Fax:
Phone: L4 o S- .252 —76 q3
Fax: Lfog- q-7--� - /02�
Job Description:
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tel' .ti �.�. � �( V �/ zt Sl,� c'`� � ✓.�G �� � kr-f'S �v`
C,::;' tAll WA C I-- CI'C- Ae 1,
Building Permit Info:
Bldg V1,— Elect Plumb Mech
Type of Construction (Usage Class): Occupancy Type:
-HT V -B
I -A, 1-B ❑
II/III/V-A❑ IUIII B, IV L�
Valuation: 106 Square Footage:
iect Size: Express ❑ Standard
Major
Green Building: Please complete relevant portion of the Green Building/LEhi) L;necxust oL auacu 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