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13050180 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 495 CONTRACTOR:VALLEY GREEN DRIVE PERMIT NO:13050180 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[] COMMERCIALS License Class Lia.#. ***UNIT#495***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:32609040.495 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMI S IF WORK IS NOT STARTED correct.I agree to comply with all city and:county ordinances and state laws relating DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to upon the above mentioned property for inspection purposes. (We)agree t save AST CALLED INSPECTION. indemnify,and keep harmless the City of Cupertino against liabilities,judgmen , costs,and expenses which.may accrue City in consequence of the p Y against said Ci Date: S Z 3 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. 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 that I 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. 1 will 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 Section 3700 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,Sect'ges 25505,25533,and 534. Section 3700 of the Labor;Code,for the performance of the work for which thisT Z 3 permit is issued. Owner or authorized agen Date 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation_provisions of the Labor Code,I must I hereby affirm 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 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 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 applicant understands and will comply with all non-point source regulation per the Cupertino Municipal Code,Section Licensed Professional 9.18. Sign re Date S 3/3 V� i 'CONSTRUCTION PERMIT APPLICATION CCP,`taUNiTY DE-✓=L0PI �-Z1*47 D_P:-',?TP:i=^' i : r,^ 1'v';& � �� _ VI :lam _ � �v U. ;J:i O . 10300 I CRR=AV tiU CUPER MING, CA,.-5014-3255 ^w I (408)777-3228 • FAX(408)777-3333 cuildineC�cu�erir:o.o,a • �'1 ❑-NEw CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERZ,D ORIGIRNAL PEZtiIIT PROTECT ADDRE A PN 9 - . .. 3 OWNERNANM I PHO/©u 6. 1 E-MAIL TR STREET ADDRESSZ(//� CTI"Y y� y / , S �ZIP�� � I FAX ' CONTACT NkmE``- �` E-MAIL' STREET ADDRESS 20 5- or CITY,ST .� _ FAX OWNER ❑ OWNER-BULDER ❑ OWNERAGENT• T ❑ CONTRACTOR ❑CONTRACTORAGENf ❑ ARCSITECT El ENGIIEER ❑ DEvmoma ❑TENANT 'CONTRACTORNAME" -' LICENSE NUMB - '1ICENSET E - - BUS.LIC# 76 - COMPANY NAME r E-MAIL FAX G STREET ADDRES / CrrY,STAT l/ / C'a �G-b d PHONE ARCHITECT/ENWEERNAME r LICENSENUMBER !R a BUS.LIC# G� y COMPANYNAME E-MAIL- FAX STREET ADDRESS CITY•STATE,ZIP PHONE DESCRIPTION OF WORK EXiSIINGUSE -- - PROPOSED LSH -CONSrR TYPE #STORIES E aSTG NEWFLOOR DEMO TOTAL AREA ARRA AREA . NETAREA BATHROOM __ KTICHEN i._.. ::. •. OTHER; REMODEL AREA. REMODEL ;REMODELAREA .. PORCHAREeL DECKAREA JOTALDECK/PORC3AREA GARAGBARV,❑DETACH .. ❑ATTACH - IDWELLIIIGLINII'S ISASECOtm TB'IIT - ❑.YESSECOND STORY AYES BEIIYGADDED+- - •.❑HO ADDTISON3.: �NO . PRS-APPLICAIION. ❑YES ffYES,PROVIDE CO$POF PIANNE2SNAtvIC. 'PLAMWGAPPLI ❑NO PLAMMMAPPROVALLEITER By my signature below,I certify to eacli of the followuig I am the prop owner of authorized gent to act on the perry.owner's:behalf. I have read ties application and the information I have rovided Is cosecs I have read Description of Work and verify rt is acc te. I agee to comply wlth all applicable local P ordinances and state laws relating to consiru n I authoresenta4ves of Cupemno to eirter the above identdied pmpety for inspection purposes Signature o£Applicant/Agent Date .1 _ SUPPI.EMEN'TAL INFORMATION REQTIlltED � - - - - - idewSFD orMuItlfam�yd�ellmgs�Adamo�Iironpernutfor ` - existmg liur�ding(S)=Demolttion penirii requ>zedpnor to issuance ofbuilding permit for new bailding Commercial B1dgs Provide a completed Hazardous Materials Disclosure a . _.. form if any-Hazardous Nfateriais are tieing vseH`as pas of this project" Copy of Planning Approval Letter or Meeting with Planning prior to SO submittal ofBu$ding Permit application. - BIdPp 2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION M ADDRESS: 20800 VALLEY GREEN DR 495 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 USE: Multi-Family Dwelling >3 Stories 0 Yes No PERMIT TYPE: i WORK ***UNIT#495***INSTALL N WASHER/DRYER HOOK-UPS SCOPE Xtech Plan Check PhImL Plan Check Elec.Plan(.,heck Lleclr.Permit Tee: Plumb.Permit Fee: Elec. Permit Fee: _L_ Li ether•.Tech.Insp. Other Plumb Insp.r0 Other Floc.Insp. d3ech.Imp. Fee. Plumb. Insp.Tec;: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,School District etc.). These fees are based on the prelhiniina information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS(Fee Resolution 11-053 E 7�j 11112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl.PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ®Yes Q No $0.00 Suppl.Insp.Fee-0 Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: T7_ $0.00 Consiruction :Tax: Administrative Fee: Work Without Permit? 0 Yes (2) No $0.00 Advanced Planning Fee.. $0.00 Select a Non-Residential Building or Structure Travel Documentalion Fees: 14 Strong Motion Fee: 1BSEISMICR $0.50 F2.0 hrs Inspections Bldy,Stds Commission Fee: 1BCBSC $1.00 $266.00 ISTINSP Inspection,Hourly $1.50 $266.00 . . $267.50 �� Revised: 04/29/2013 i FORNPI 0110 4� COMMUI\1I i Y DE`✓ELOPiAENT DE PAIR T MEIN• BUILDING DIVISION 10300 TORRE AVENUE•CUP_RTINO; CA 06014-3266 (403)777-3228• FAX(408)777-3333 bis Fdin t urnrlrn .o-a . CUPERTINO? Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN I BP4 OWNER NAME � OWNER ADDRESS _ 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 understanding of each provision,signed,and returned this form to us at our official 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 ACKNOWLEDGMENT AND VERIF[CATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) /1. I 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 personally. 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 insurance coverage for injuries to workers on my property. S'/2. I 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: SV3.1 understand as an"Owner-Builder" I am the responsible party,of record on the permit... 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. c /4. 1 understand Contractors are required by to be licensed and bonded in California and to list.their license numbers on permits and contracts. J5. 1 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"under state and federal law. , 1/6.I understand If 1­4 considered an `employer"under state and federal iaw;,I must register:with the state.and federal governmentT withhold payroll faxes, provide workers'compensation disablltty Insurance, and contribute to unemployment compensation#or each"employee !also understand my failure to'abide by these laws may subject _ r meta seriousfiddhcial risk. understand under Califomia Contractors'State License Law, art Owner Builder who builds single-family residential structures cannot legally build them with the intent to offer them,for sale; unless all.work is performed by licensed subcontracfors and the numiier of sfructures does hof exceed-four witfiin any-calendaryear,-or all-of the-work is performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal::injuries sustained by'anysubsequent owner(s)that result from any latent construction defects-in fhe,workmanship or materials. rerBuilderFornz 2010.doc revised 04/14/10_', f-)-9. I 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 License Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed contractors. :�I_/ 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. .5111. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. S_d12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to -:assist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or .employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder 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 Civ.) , 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 property 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: rr� Date: $'-oZ (NOTE.•,The following Authorizatian Form is required to be completed by the property owner only when designating an agent of the property owner to'applyfor a construction permit for the Owner-Builder). All THORlZAT{ON OF AGENT TO ACTON PROPERTY OWNER'S BEHALF Excluding the Notice to Prgperty.Owner,the a cecutlon of which 1,understand is my personal responsibility, I hereby aufjionze,the following person(s)to act as.my agents)to apply for, sign, and file the documents necessary to obtain an. OvVner Builder Permit for my project. Scope ofConstruction Project(or Description of Work): Pro ect Location or Address: . J: I ,Name of Authonzed Agenf Nb ,- Tel.No: address ofAuthonzed Agent I deefare under penalty of penury that!at7t the property owner for the address listen above end I persorially filled out the. r. above information`and cetrfy{ts accuracy Note:A copy of the roe owner's drivers license,'form notarization, or other P R. Y ven 7cat!on acceptable to the city may be required to be presented when the permit is issued to verify the property owners .-signature. Property Owner's Signature: Date: Oii>>aerBudderFonn 2010.docrevised04/14110