13050179 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 446 CONTRACTOR:VALLEY GREEN DRIVE PERMIT NO:13050179
OWNER'S NAME: VALLEY GREEN DRIVE P.O.BOX 1368 DATE ISSUED:05/23/2013
OWNER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL0
License Class Lic.# ***UNIT#446***INSTALL(N)WASHER/DRYER HOOK-
UPS
Contractor Date
I hereby affirm that I am licensed under the provisions.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. Sq.Ft Floor Area: Valuation:$500
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 APN Number:32609040.446 Occupancy Type:
permit is issued:
APPLICANT CERTIFICATION
I certify.that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.'I agree to comply with all city and county ordinances and state laws relating WITHIN 180 F PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned propertyfor inspection purposes. (We)agree to save 180 D RO AST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which'may accrue against said City in consequence of the Date: Z 3 3
granting of this permit. Additionally,the applicant understands and will comply Iss
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 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.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm thatI am exempt from!the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business:&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. twill.
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 5505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which thisJ "Z
Owner or authorized agent.
gent Date:
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 mamrer'so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY
Compensation laws ofCalifornia.,Ily after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affurn that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all cityand county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspectionpurposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which.may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally;.the appli t understands and will comply
with all non-point source regulations'per the pertino Municipal Code,Section Licensed Professional
9.18.
Si tared Date l
'Of,41STRUCTION PERMN' "C.-TION'
.......... A 1 61
COI'AHMUNITY DEF —1 0E—t.A_'__!"iT
MOO TO
RE AVEN CUPFERTIN0, C2 �5014-3225:,
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CUPLRTING (408) 777-3228 - ,--,'X(408)777-3333-
❑NEW CONSTRUCTION ❑ ADDITION El_AL—i_,:ZA-Tio,,r -i i Ej REVISION DEFEF—ICEED MG—TKAL PF_2V,rT
PROJECT ADDRESF
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DESCRIPTION OF WORK
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By my below,I cert each
i4y ; certify to 9ft4qfollowing--Ja
application the iufomationi4a7#provided
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tate laws ielatin to builp ;?f5 rt rs accurate I agree to comply wrth alI applicable local;'
e representatives of CTiper[Ino to entez the above dentified propert/y for inspection purposes
'5.
SUPPLEMENTAL INFORMATION REQ
`Q-
b-
ce u
perbait fornew bnUdin
Commercial Bldgs
ld c8r'pl�i6dHazdousMteils Disclosu,,
fomifafiy1-zardous Ma �iialscie being- d
use asparvo_f fbisn,-oje
Copy of Plwr g Approval Leer or Meeting with Pla=Lg prior to
sub-ittal o a-0plic7aEon.
-03116
_2011-c-'bc re-vised
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
F,91 ADDRESS: 20800 VALLEY GREEN DR 446 DATE: 05/23/2013 REVIEWED BY: MELISSA
APN: 32609040.446 BP#: *VALUATION: $500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
:PRIMARY Buildina is PENTAMATION
Multi-Family Y Dwelling >3 Stories ® Yes 0 No PERMIT TYPE: i
WORK ***UNIT#446***INSTALL N WASHER/DRYER HOOK-UPS
SCOPE
Mech.Plan Check Phimb.Plan Check Elec..Plan Check
JWch. Perinit Fee: Plumb.Permit 1%ee: I Elec. Permit Fee:
[1'41e`ch1
Alech.Ins). Other Plumb Insp. Other Elec.Insp. L—i 1L]
Insp.Fee. Plumb. Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the prelimina information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 E . 711/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl.PC Fee: Q Reg. QOT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly.Only? ®Yes Q No $0.00
Suppl. Insp.Fee.0 Reg. OOT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tai
Administrative Fee:
Work Without Permit?' ® Yes Q No $0.00 G
Advanced Planning Fee. $0.00 Select a Non-Residential
Building or Structure
'1'ral>et Documentation Fees*.- I I �
Strong Motion Fee: 1BSEISMICR $0.50 2.0 hrs Inspections
Bldg Stds Commission Fee: IBCBSC . $1.00 $266.00 1STINSP Inspection,Hourly
$1.50 $266.00 $267.50
\ Revised: 04/29/2013
6
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COt�!t�Ut !TY ✓=LO�ty=NT D_RA"R T tAENT.7U!LDiNG Di' 1-JON
10300 TORR=AVBNU_ CU?=RT!t!O; CA 95014-325
CU P E RTI N r I (408)777-3223 FA:(403)777-3333
Dear Property Owner(s):
An application fora building permit has been,submitted in your name listing yourself as the builder of the property
vements--speci:ied at: - ----- — -- —
SITE ADDRESS Ay BP4 O�G
--- OWNER NAME _...--j\ � � �NEl�7�
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment and information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understarsding of each provision,signed,and
returned this form to us at our officiat address indicated. An agent of the owner cannot execute this notice unless
you,the property owner,obtain the prior approval of the permitting authority.
OWNER'S ACKN.OWLE136MENT AND VERIFICATION OF INFORMATION
(DIRECTIONS.Please read and init/al each statement below to signify you understand or verify this information.)
65 611. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material
persd Tally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. i am willfully acting as an Owner-Builder and am aware of the limits of my
cin�su/rance coverage for injuries to workers on my property.
J 1/ 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility:
5
_�/3. 1 understand as an"Owner-Builder" I am the responsible party,of record on the permit, l understand that i may
protect myself from potential financial risk by hiring a licensed Contractor and.having the permit filed in his or her
name instead of my own.
5�1'4. 1 understand Contractors are required by to be licensed and bonded in California and to list their license
�numbers on permits and contracts.
J 5. I understand if I employ or otherwise-engage any persons, other than California.licensed Contractors, and the
total value of my construction is at least five hundred dollars($500),including labor and materials,I may be
considered an "employer"understate and federal law
6. I understand if I am considered an `employer"understate and federal law,:_I must register with the state..and
federal government,wrfhhold payroll taxes, provide workers'.compensation disabliity insurance;and cottnbute to
unemployment Com ensation foreach' em lo: ee l`also understand m failure to.'abide:b these laws:ma sub ect
- p..,_ P. .y _ Y Y Y J
_ ,
me to serious-financial risk.-
S!i°7. 1 understand.under California Contractors'State License Law, an Owner Builderw✓ho builds single-ramify
residential structures cannot legally build them with the intent to osier mem for Sala, unless alf work is performed by
censed subcontractors and the number of structures does not erc ed our v !_hin any-calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
S S.f 1 understand as an Owner-Builder if I sCil the prop_=i y for%vhich l pis permit is issued I iiiay be lheld liable
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects-in the workmanship or materials.
P rezzrihzrrol iiz 2010.doc revised 0411?/10
I
a
7 •
9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
,Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
1:icense Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed
contractors.
j/10. 1 am aware of and consent.to an Owner-Builder building permit applied for in my name, and understand that
am the party legally and financially responsible for p>oposed construction activity at the site address listed above.
11._1 agreethaf, as-the party_legally andfnancially responsible..for this-proposed construction-activity, f will-abide..
__by_a.fLappli ablP laws'and rPiiniremPnfs P t `_vein Qwner_B_uilders as well as_empfoy_els
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I h.ve_provided on this form Licensed-contractors are_xegulated by laws designed to,protect_the public_-If
you confract witfi someone w o oes no ave a icense, the Confracio s= tae-Gcens oarct may be Tin"able fo""�
-tassist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed
Contractors maybe in civil courf It is also important for you to understand that if an unlicensed Contractor or
,employee of that'in. Jvi, ual or"firm is injured iiwtiile working on your property,`you may tie held liable for damages:If
you obtain a permit a80 Wher-Bbilder and wish to hire-Contractors,you will be responsible for verifying whether or not
;-those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby.affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Cfv.)
Lender Name: Lender Address:
Before a building permit can be issued,this-form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the properly owner's driver's license,
form,notarization,or other verification acceptable to the city may be required to be presented when the permit is issued
to
verify the property owner's signature.
Property Owner's Signature: Date:
J.
-_ ---__---`------_---------------.__:___-_---__------------------------------- '----' -----------
------__------------------------.-----
(N0TE.,The following'Authorization Form is required to be completed by the property owrjer only when designating an
agent of the property owner to apply for al construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO AGT.ON PROPERTY OWNER'S BEHALF
Exi lading the Notice to Pr-oper[y.Owner,the execution of which I understand is my personal responsibility; 1 hereby
auttionze„the following persons)to act as.my'agent(s)to apply for, sign, and fife the documents necessary to obtain an
OvtiherrBuilder Permit for my project.
Scope`of.Construction Project(or Description of Work):
Project Location or Address:
3
Name of 6thorrzedAgent
Addhess ofAuthotized Agent `
I fire rare UndCr si laity of perjut.y that I am ii ie props y owlIUer for the address fisted above and I persOnally f`11 �^ut the
above information and eerlify its accuracy Note:A copy of the propertyowners drivers license, form notarization, or other
Verification acceptable to the city may be required to be presented when the permit is issued to verify the proper l owner`s
signature.
Property Owner's Signature: Date:
- Ov se7,3uilderFonn 2010.doc revis d 0'/14/_10 -