13080240 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR, CONTRACTOR:UBS PERMIT NO: 13080240
OWNER'S NAME: UBS 20800 VALLEY GREEN DR DATE ISSUED:08/30/2013
OWNER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# APT#498-INSTALL(N)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
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; p D 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 DAYS CALLED INSPEC ION.
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:
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 isnot 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. I 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,Se1tiel�s 25505,25533,an 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized a nt:\ 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 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 regulations per the upertino Municipal Code,Section Licensed Professional
9.18. <'
l
Signatur / '?.� Date v,
V
CONSTRUCTION PERMIT APPLICATION
CONSTR p
�
2
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 O
CUPERTINO (408)777-3228•FAX(408)777-3333•building0)cugeitino.org \�
❑NEW CONSTRUCTION ❑ ADDITION C❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS AFN# 9r f
OWNER NAMP PHO E-MAIL
STREET ADDRESS CITY. Q E,ZIP D� FAX
CONTACT NAME PHO E-MAIL
STREET ADDRESS CJIY,ST ZIPe� FAX
� rPi'l /�
OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT O CONTRACTOR CI CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME w J n E-MAIL FAX
STREET ADDRESS ( CITY,STATEZ17 PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORKAi
Gt/
EXISTING USE PROPOSED USE CONSTR.TYPE #STORnS
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEWFLOOR DEMO - TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL
4*
AREA GARAGE AREA: DETACH[-]ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES. SECOND STORY ❑YES
BEINGADDED? ONO ADDITION? ONO
PRE-APPLICATION DYES IF YES,PROVIDE COPY OF IS THE BLDG AN 5 TOTAL DATION:
PLANNINGAPPL# ONO PLANNING APPROVALLETTEREICHI.ERHOME?
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prl_peM owner's behal 'I have read this
application and the information I have provided is correct I have read the Depription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating tog nsttuctio . I authorize re tatives of Cupertino to enter the above-ide(n+tiified propertyforinspection purposes.
Signature of Applicant/Agent: Date; c'S l
SUPPLEMENTAL INFORMATION REQUIRED PLAN C$ECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for OVER-TH"OUNTER ❑ BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building T
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORxs
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 ElMAdoR El SANITARY SEWER DISTRICT
submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTEt.
Bldgf4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20880 VALLEY GREEN DATE: 08/30/2013 REVIEWED BY: MELISSA
APN: 32609040.498 BP#: *VALUATION: $500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY Multi-Family Dwelling Buildina is PENTAMATION 1 RMAP1
USE: 1 >3 Stories 0 Yes (D No PERMIT TYPE:
WORK APT#498 - INSTALL N WASHER/DRYER HOOKUPS
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 1BAPPLOT 2 # $140
TOTALS: $140 00
Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Check Elec..Plan Check
Mech.Permit Fee: 1MPERMIT Plumb. Permit Fee: Elec. Permit 1'ee:
Other Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp. Other Elec.Insp.
Alfiwh.Insp. Fee: Plumb.Insp. Fee.. Elec.Insp.Fee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Theseees are based on the pirelindna information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711112) FEE QTY/FEE MISC ITEMS
Plan Cheek Fee:
,5'ztpl)l. PC Fee'
PME Plan Check: $0.00
Permit Fee.:
Suppl. Insp F•ee
PME Unit Fee: $140.00
PME Permit Fee: $47.00
Construction .Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes e) No $0.00
Advuneed Plantzing FeeS: Al
Travel Documentation Fee: 1TRAVDOC $47.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
`£� 9 EEr00$279.50 $0.
$279.50
Revised: 07/01/2013
1
0 1011NE =BUlf I DER D1SCf OSaURE F 0 R[,01
COMMUNFY D=VELO !,%=NT DE �ATi,,�}�'i i :�
i ,
31jiL i NG ..ION
10300 T ORRE AVENUE •CUPRTINO,CA 95014-325.5
CUPEI�TIP.EO (4 --AX
03) 777-3223• (408) 777-3333 • b,iiain� c_�e, inv.or�
Dear Property Owner(s):
-An application fora building-perint has-been submitted in-yodr-name listing yourself as the,bui[der.of.the property -
SUE ADDRESS APN BPI
owNER N-"r :.- .. .. .. . OWNIFR ADDRESS...... . _._.. ._.
Fi P11 J/01,7 opi
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 permlt until you have read,initialed your understariding of each provision,signed,and
returned this form to us at our officlaf 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 ACKNOWLEWMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS.Please read and initial each statement below to signify you understand or verify this information)
SIL1. 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 properly 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. 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.
�) 2.1 understand building permits are not required to be signed by property owners unless they are responsible for
the�constl-uction and are not hiring a licensed Contractor fo assume this responsibilify:
c�i✓ 3.i understand as an"Owner-Builder"I am the responsible party,of record on the permit, i understand that 1 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.
j 4.i understand Contractors are required by to be licensed a
(end-bonded in California and to lis#their iicense
numbers on permits and contracts.
�5.I understand if I employ or otherv+rise engage any persons, other than California licensed Contractors, and the
total Value of my construction is at least five hundred dollar's($500); including labor and materials,'i may be
considered an"employer"under state and federal law:
/ i understand rf I am considered an"employer"under state and federal law, 1 thiti state and
federal governtrienf,ivrttlhold payrolltaxes, provide workera'compensation clisab�ltty insurance,and contribute to
unemployment compensation for each'"employee"l also understand:'my failure to abide by thesetaws may subject
me o'serious-financial risk_
,MTI understand,under Californla Contractors' State License Leet, an'04vner Builder who builds single-family .
residential structures cannot legally build them with the intent to oiler them for sale; unless all vrork is p-arrormed by
licensed subcontractor and the number of structi,es does not exceed fourr W!"11141 any calendar year, or all of the work
is pei,"ormed under contract with a licensed general building Contractor.
O. 1 understand as ail Owner-Buiidar if I sell the propel-Ly or',;moll ti-!is rri:a is issued, 1 i'ay be hind li:2b!tr -Cr i
uny riancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects.in the workmanship or materials.
- Ota r r
r_3r ilr'rrFo'M 1010.aoc ra.vi ed 64/.!_x/_10,, E
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 1-800-321-CSLB (2752)or www.csfb.ca.gov for more information about licensed
contractors.
_,g:P, .t
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 constructtion activfty at the site address listed above. .
SIZ11. I agree..fhat, as_the party legally and,financlally responsible for this proposed construction activity, 1 wiH abide
--------------6y--alt aPpiicablelaws altr3 ceq�rements.that-�ousrn.-Owner-Builders-as.w_eILas-Employers----
S t/12. 1 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 taws designed to protect_the public. if
- :yoia con racf wi someone who-does nof-have a[rcense,the o�ifracfors' tate ti`Sense-8-0 d-111 T utiatif a trs� -----
=:assist you with any financial loss.you may sustain as a result of a complaint.Your only remedy against unlicensed
Contractors may an civil-court.It is also important for yoy to understand that if an unlicensed Contractor or,
'employee of that individual or firm is Injured tiniftile working on your prbperty you may be held liable for darna.ges.'If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying.whether or not
'Pose Contractors are properly licensed and the status of their workers'compensation insurance coverage.
GlQNSTRUCTION LEND'INO AGENCY
(DfPECT10NS: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:
1300' re a building permit can be issued,this-form must be completed and signed by the property owrier and
returned to the agency responsible for issuing the permit. Note:A copy of the properly owner's driver's license,
forri .notarization, or other verification acceptable to the city ay be required to be presented when the permif is issued
to Verify the roe owner's si natur .
Property Owner's Signature: :Date:
.
-----------------------------------------------':::----------------=------- --- - -----------------------------= ------------------- "
(NOTE:,The follpwing Authorizatlan Fonn-ls required to.be completed by the properly owrjer ohly when designating an
agent of fh'e property owner to apply for a bonstructlon permit for the Omjer-Bullder).
SLG w AUTHORIZATION OF AGENT TO ACT.ON PRQFERTY OWNER'S BEHALF
',` xi;li dtng the Notice to Rrgperty.Owner,the execufiori of which l•understand is my persona!responsibility, I hereby
auti orize,the following person(s)to act as my:agent(s)to apply for,sign, acid file the documents necessary to obtain an
Owri'ec'Buflder Perml for my project.
onstructlbh Project(or Description of Work):
"'Pro
ject,Ldcation orAddress:
,a I
i Narlie„of Autnonzed k
Agenf � Y ? Te!No
' 6 Ac
Address"ofAuthorized-Ab
eiit:r•,f, .
!d`ec[are under penalty of penury that i aril the propel tjr vvrner for the address listed ab e and I personallyfiflbd out the
above'inforrriation and certify its:accuracy..Note:A copy of the property owner's drivers Iicerise, form iiotarizatidn, or other
_ .
veritrcation acceptable to the city may be required to be presented when the pen-nit is lsscied to veri,9/the property owners
signature_
Property Owner's Signature:-- ------------------- -- Date:.___---
-
Oicrar'..!aldet7�o�n 2QI0.dori•evzs=,Q;'l14/10 .
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C O P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: 2 Ll 0 1,1,0111e,,1f-Qew : PERMIT# o13d`Z
OWNER'S NAME: PHONE# {O6 Z, •z
GENERAL CONTRACTOR: BUSINESS'LICENSE:
ADDRESS: CITY/ZIPCODE
*Our municipal code requires all businesses working in the city to have a City of.Cupertino;business.license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) 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.
SUBCONTRACTOR BUSINESS NAME. BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date