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09110024CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20875 VALLEY GREEN DR #40 CONTRACTOR: DEVERA CONSTRUCTION PERMIT NO: 09110024 INC. 'NER'S NAME: KORET FOUNDATION 941 D BERRYESSA RD DATE ISSUED: 11/05/2009 0-YNER'S PHONE: 4082530200 SAN JOSE, CA 95133 PHONE NO: (408)441-9598 0 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT F PLUMB License Class Lic. # MECH I— RESIDENTIAL f— COMMERCIAL r Contractor Date JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE, 1 hereby affirm that I am licensed under the provisions of Chapter 9 COMMERCAIL (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. 1 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 APN Number: 32609064.40 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 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 by -'"`_------'>"_ Date: S: ture Date RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is ® OWNER-BUILDER DECLARATION 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: 1, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the stricture 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 the Cupertino Municipal Code, Chapter 9.12 and the Health & performance of the work for which this permit is issued. compliance with p Safety Code, Section 25532(a) should I store or handle hazardous material. 1 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, 1 11 Owner or ai,�ho; izell age Date: l 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 constriction 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.) Lender's Name 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 I 'ie above mentioned property for inspection purposes. (We) agree to save Lender's Address ii. nify and keep harmless the City of Cupertino against liabilities, judgments, costs, 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 1 understand my plans shall be used as public records. 9.18. l © Licensed Professional Signature ` Date CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609064.40 DATE ISSUED.......: 11/05/2009 RECEIPT #......... BS000009129 REFERENCE ID # 09110024 SITE ADDRESS 20875 VALLEY GREEN DR #40 SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER KORET FOUNDATION ADDRESS 20875 VALLEY GREEN DR CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM KORET FOUNDATION CONTRACTOR HENRY DEVERA LIC # 24605 COMPANY DEVERA CONSTRUCTION INC. ADDRESS 941 D BERRYESSA RD CITY/STATE/ZIP SAN JOSE, CA 95133 TELEPHONE (408)441-9598 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 42.00 1TRAVDOC FLAT RATE ---------- ---------- ------0_00 ---------- 253.50 0.00 253.50 0.00 TOTAL PERMIT METHOD OF PAYMENT AMOUNT -- - REFERENCE NUMBER ----------------- --------------- CASH 253.50 --------------- TOTAL RECEIPT 253.50 cm Of CUPEkTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # -� — _ `T Date: / 1 Building Address: r 4� p Vu /1 c d eve ��o Mailing Address (if different fro buildin address): w Owner's Nar--- Phone #: tq v HOA: (Exterior work only) Yes U No If yes, provide letter from HOA Contractor: Phone: Fax: Contractor License #: Cupertino Business License #: Contact: Phone: �' 11•Cl,�uG{ � tutst/ Fax: L4 vet- l 3 - I0 ZS Residential Commercial ❑ Job Description: 1�s�� [ / VjGs(-"-Qv / .7 ` UL" Cb tM efC(,4, l ✓'i (M QwT �J l• ���'� Building Permit Info: ,� �/ �/ / Bldg If Elect LTJ Plumb LJ Mech Lid' Type of Construction (Usage Class): Occupancy Type: II/III/V-A V -13A 1-A, 1-B [-] II/III/V-A B IV -HT ❑ —Z Valuation: loo Square Footage: Project Size: Express ❑ Standard [V/ 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.b 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. L� A portion of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to PeV , ,Y � � P,e i O� X 41 (e (7 S AWA T OSe C 1� S, 8 CG.. V -k CIS D v Sly I�oY�w ct�� 8S k& P�- 91 - (0 0 -- (034 S' Sa," 0092, u 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 ;;Y Qi � I - j 3`"� • �2JC) II.Lru h'l, k('n � d$�'S Vail-� uk vto4 u I declare under penaty of perjury, that the above is true and correct. I have read and understand the Owner -Builder Information (reverse side). Property Owner's Signature: nn Job Address: a0cj S I�OdI� v\ dy, # l e.IAb ('_•A Date: 1lI5l0q Permit # Anglian es to the. information provided on this form shall be submitted to the City of Cupertino Build Department.