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13080241
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20990 VALLEY GREEN DR CONTRACTOR:KORET PERMIT NO:13080241 FOUNDATION/UBS OWNER'S NAME: KORET FOUNDATION/UBS 20875&20990 VALLEY GREEN DR DATE ISSUED:08/30/2013 OWNER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL11 License Class Lie.# APT#607-INSTALL(1)WASHER/DRYER HOOKUPS 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 1 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:32609053.,Pe 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 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY 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 � d ate: 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) 5' 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,Secti s 25505,25533,an 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:( 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 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 constriction 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-poi ource regulations r the Cupertino Municipal Code,Section Licensed Professional 9.18. 1 S ature Date r / CONSTRUCTION PERMIT APPLICATION 1 COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95094-3255 GUPERTINO /�„�J (408)777-3228•FAX(408)777-3333•buildingCd)cugertino.org \ ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS Q /� Q APN$ ry 3 OWNER NAME Ro IS{> fes- f� NE .. �O , E MAIL P,tr STREET ADDRESS® G ' 10->-, CITY,ST ZIP l! G C FAX CONTACT NAME PHONE E-MAIL J STREET ADDRESSCITY.STA P `ADDRESS = FAX Ger. OWNER . ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE T Y?E� BUS.LIC# z3f)kI3 = V COMPANY NAME E-MAIL ILI FAX 144or STREET ADDRES�)() larippirld-ed mad CITY,ST TE Zu �' �� PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK .Y rGAkio v- 3 EXISTING USE PROPOSED USE CON SM TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODELAREA REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH - ATTACH #DWELLING UNrrS: IS A SECOND UMT YES SECOND STORY []YES BEING ADDED? [3-NO ADDMON? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF - IS THE BLDG AN ❑YES RE BY' - TOTAL V ATION: C^0 PLANNING APPL# ENO PLANNING APPROVAL LETTER EICIH.ER H011'!E? []NO By my signature below,I certify to each of the following- I am the property owner or authorized age a property owner's behalf. I a e read this application and the information I have provided is correct I have read;he Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ' g constru 'on. I authorizirepresentative5 of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: CD Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROVrA'IG SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for AOVER_THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ mREss ❑ PLANMG PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR ❑ gpHIrARy gEwER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH. Bldgtipp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20990 VALLEY GREEN#607 DATE: 08/30/2013 REVIEWED BY: MELISSA APN: 32609053.607 BP#: "VALUATION: $500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/Repair PRIMARY Multi-FamilyDwellin Building is PENTAMATION 1RMAP1 USE: 9 >3 Stories ® Yes ® No PERMIT TYPE: WORK APT#607 - INSTALL N WASHER/DRYER HOOKUPS SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 1BAPPLOT 2 # $140 TOTALS: $140 00 EM Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Cheek Elec.Plan Check Mech.Permit Fee: 1MPERMIT Plumb.Permit Pee: Elec. Permit re.: Other Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp, Other Elec.Insp. Il�ech, Insp.Fee: Plumb. h7sp. Pee: Elce.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 fees are based on the prelimWina information available and are only an estimate Contact the Dept for addn'l info, FEE ITEMS (Fee Resolution 11-053 E . 7f� /1/12) FEE QTY/FEE MISC ITEMS Plan (.'heck Fee: ,Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: .Suhpl. Insp F'ee PME Unit Fee: $140.00 PME Permit Fee: T7 $47.00 (.'onsir uction :Tax. Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes (E) No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAVDOC $47.00 Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg,Stds Commission Fee: IBCBSC $1.00 kA $279.50 .0 � _ $279.50 F$00 r Revised: 07/01/2013 � I4�J `1j =i1 f€ 1 -C E -.S' URE €O R A'f i COlvMUNIfTY D=V_LO'h'I. �, i f,i=i�'T BUiLDfi�u Vii':i O,N 10300 TORRE AVENUE •CUPERTINO,C,05014-3255 CUP ERTi f t t) (408)777-3228• FAX(408)777-3333 • Dear Property Owner(s): . -An application for a bbilding permif:has-Been submitted in-yodr-name listing yourself as the:builder of_the property SITE ADDRESS ® to Qf �8 APhi + BPS OWNER NAME .. _ _ �N ..c. : OWNEFZADDRES`5 _ _... ... A/ AdZi 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 AC KNOWLEROMENT AND VERIFICATION OF INFORMATION (DIRECTIONS.Please read and initial each statement below to signify you understand or verify this information.} 9. i understand it 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. 1, 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. l am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 112.1 understand building permits are not required to be signed by property owners unless they are responsible for the constrriction and are not hiring a licensed Contractor to assume this responsibility: 5J13.i understand as an"Owner-Builder"1 am the responsible party,of record on the permit. I 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. 4,4. i understand Contractors are required by to be licensed and bonded tri California and to lis#their iicense numbers on permits and contracts. 5 _5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the totai Value of my construction is at least five hundred dollars($500); Including labor and materials,l may b.e considered an"employer"under state and federal law; Sfi 1 understand if I am considered an"employer"under state and federal law, I must regrster wrth the state and federaf government,wrthfiotd payroll taxes, provide tn!oikers'"compensation dlsabrlrtyinsurance, and contrrbute to -. p Y p p y " Y Y theselaws may subject �." me.to serious fnanctal r sk�on for each em io ee !also understand'm farlure to abrde b /7. 1 understand.under California Contractors'State License Law,an Owner Builde'rwho Builds single-family : residential structures cannot legally build them with the intent, offer mem for sate; unless a/I v,ork is periormed by icensed subconttao ors and the number of StFU LC f I F JF�'3 does not elce-ed aur Wi:1h i n ar?;/ca-tendaryear, or all ci the vmiR is pei,"ornied under contractwith a licensed general building Con")aCL o'.'I understand as an Owner-Builder If I soil ii e j)MD�i iY 10; TTTiTTT D)Gn i : BTJFf. i '^sred, I ay ,': 11 ?b ' 7-IDi any financlal or persona(injuries sustained by any subsequent owner(s)that result from any intent construction i defects.in the works nsl ip or materials. J Oil ri-B r7, -7'F01_)77 "070-01100 1"t'1'Zif G�/1 ALIO' 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 License Board(CSLB)at 1-500-321-CSLB (2752)or www.csib.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Qwner-Builder building permit applied for in my name, and understand that I am the party legally artd financially responsi6ie for proposed construction activity at the site address listed above. 11..i agree..#fiat, asahe partyl 60allyand-financially responsible for this proposed construction,activity, i will abide ---------_----I�y aU-applirabie laves°anr3regdirerrisnts that .ovEin.D_iunez�uild$.ts as_mILas-employers- t_311 s eniployers_3jL 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information j have provided on this form.Licensed contractors.are.reguiated,by Iaws designed to.protect the-public. If - you-con�rac�fwit�someone +�v�o does nof�iave a ticense�tC�e-Co�i�actors'�tate Li`se7is�B�iar�irta�r bettilable fio - --� -� ..assist you with any financial loss.you may sustain as a result of a complaint.Your only remedy against unlicensed Contractors maybe incivf!court.-l. It is also important for you to understand that if an.unficensed Contractor or, employee of that individual or'ftrrn is injured:viiltfie wolcing on your prbperty you may tib held tia6le for damages:if you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying,whether or not ;rthose Contractors are properly licensed and the status of their workers'compensation insurance coverage. r • CONSTRUCTION LENDING AGENCY (DYIECTIONS:Please complete the following construction lending agency information.) I hereby.affirm that thereis a construction lending agency for the performance of the work for which this pormit is issued (Sec 3097 Civ.) 1 i Lender Name: Lender Address: Before a building permit can be issued,this.form must be completed and signed by tho property owner and returned to the agency responsible far issuing the permit. Note:A copy of the property owner's driver's license, forrn.notarization, orother verification acceptable to the City requlred to be presented when the pennitis issued io.Vedfy the propertk owner's signature. T?r 'pei#y Owner's Signature: :Date: s f . .-=--------------------=----------------------------------------=---=-------=--- - --___--------- -------------- --= -------=----------- ;=(/VOTE.+•The followingAuthorization Form-ls iequlred to bs completed by the properly owrjeronly when designafirig an agent of the propbdy owner to apply for a'nohstiz 6 lon permit for the Owner-Buikfer). ate AUTHOR[ZAT[ON OF,AGENT TO ACTe.ON PROF?ERTY O11E NER'S BEHALF : Picpfuciing:the Notice to Pr'operty.Owner,the execution of which! understand is my persona!responsibility, Thereby authorize the following person(s)to act as.myapent(s)to apply for,sign, arid fife the documents necessary to obtain an ' . Owhe.r-Builder Permit for my project. r:.. cope`;of; onstruction Project(or Description of Work): P j mW I Pro�e6t Location or Address: 1 r x iy �y F f i r t �, Narpe of Aut�torized Agenf� �> � ~ Tef No n� '1',r�a6:y✓° f zA Address ofAuthorized'Hgent: .•}. l' I ideclare under Pena{ty of perjury that i am the property c„me 'for the address listed' b e and I p-ersonalh illed out th above:inform6tion;and certify 1ts:accuracy:Note:A copy of the property owner's driver's hcerise, form hotarizatidn, ar other.. verification acceptable to the city maybe required to be presented when the pen-nit is issued to verh9l the propexji owners signature- Property Owner's Signature: -- -- Date:.___--- D sr,a,r,rVd rFons `Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: Z© Q l c Pn 7066 PERMIT# OWNER'S NAME: 12E T 1'dAADW71J,,V PHONE# C' cL GENERAL CONTRACTOR: BUSINESS LICENSE#'_" ADDRESS: CITY/ZIPCODE: ' *Our municipal code requires all businesses working in the city to havea City of.Cupoi61 b;business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL;BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Jor Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile �k Owner/Contractor Signature 12 . Date