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13080239 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR f CONTRACTOR:UBS PERMIT NO:13080239 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❑ COMMERCIAL11 License Class Lic.# APT#445-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.Av 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 WITfIIN 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 FINSPECT ON. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City inconsequence of the granting of this permit. Additionally,the applicant understands and will comply by Date: 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. 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,Sectiones 25,505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: c 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 th Cupertino Municipal Code,Section Licensed Professional 9.18. � Signature Date - 3 CONSTRUCTION PERMIT APPLICATION © 1/ Li 1 COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228 FAX(408)777-3333 building aecupertho.org CUPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN Z=/) 4" OWNER NAME U C PHONEE-MA ` IL STREET ADDRESS J CITY,STATE P FAX �r r� CONTACT NAME PHONE E-MAI J STREET ADDnS CITY,ST ZIP FAX OWNER ❑ OWNER-BUILDER ❑OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# 60 G• COMPANY NAME/J/� - E-MAIL FAX STREET ADDRESS V� CITY,ST Z1P Il r� r PHONE` `ry� `Gd ARCHITECT/ENGINEER,NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR-TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMOD£LAREA REMODEL AREA. REMODELAREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ATTACH #DWELLING UNITS: IS A SECOND UNrr YES SECOND STORY ❑YES BEING ADDED? [3140 ADDITION? ❑NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES 'COT V ATION: PLANNINGAPPL# [INO PLANNING APPROVAL LETTER EICHLERHOME? E3 NO «'V By my signature below,I certify to each of the following. I am the property owner or authorized age a e prpperty owner's behalf. I fiave read this application and the information I have provided is correct I have read die),lelcripton of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to g constru 'on. I authorie r tatives of Cupertino to enter the above-identified property for inspection purposes. Signature of ApplicandAgent: % Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for V OVER-THE-COUNTER ❑ BUMDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ ExPREss ❑ PLANMC PLAN REVIEW -To—rm. Commercial Bldgs: Provide a completed Hazardous Materials Disclosure r-1STANDARD 13 PUBLIC WORKS form if any Hazarddous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to C3 MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH Bldg',4pp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 20860 VALLEY GREEN DATE: 08/30/2013 REVIEWED BY: MELISSA APN: 32609040.445 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 ® Yes ® No PERMIT TYPE: WORK [An#445- INSTALL N WASHER/DRYER HOOKUPS SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 1BAPPLOT 2 # $140 TOTALS• r "3 $140.00No ; Mech.Plan Check 0.0 hrs $0.00 Phunb.Plan Check Elec.Plan(,hack Mech.Permit Fee: IMPERMIT Plumb. Permit bee: Flec. Permit Fee: Other Mech.Insp. 1 0.0 1 hrs 1 $47.00 Other Plumb Insp. Li Other£lac.Insp. Alech. lnsp. 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). Theseees are based on the relimina information available and are only an estimate. Contact the Det or addn7 in o. FEE ITEMS(Fee Resolution 11-053 E f' 711112) FEE QTY/FEE MISC ITEMS Plan Chock Fee: S'uppl. PC Pee PME Plan Check: $0.00 Pe Fruit Fee: Supp/. Insp Fee 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 ldvancc;d 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 w . o $279.50 $0.00PR .t) '.E - $279.50 Revised: 07/01/2013 F 0tT1fYfEq=PU1fLDER DISCI 043URE FOR6 COtvif�iUf��f i O=VEL OJh4=1v i 1'=:A,TMjE14'I 31iiL�NG �i'.'i ii N 10300 T ORRE AVENUE •CU?ErRTlNO,CA 95014-3253 eUPERTIhEC3 (408)7773228- ;--AX(4081777-3333 • li Gln i �_��_in•^- Dear Properly Owner(s): -An applica#ion for a b6ilding perrmt has been submitted in-your name fisting yourself as the.builder ofthe property SITE ADBRESS � AMn I BPS - - Z OWNER NAME ; -: . . _.. .._. --. OLNNEE2 ADDRESS..:� C J t� DESCRIPTION OF WORK: Q`>t4/20 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 ACKNOWLEWMENTAND VERIRCATiON OF INFORMATION (DIRECTIONS.Please read=and Initial each statement below to signify you understand or verify this Informafion.) �. 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. 1, as an Owner-Buildef,may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his orher 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 constriction and are not hiring a licensed Contractor to assume this respoizsibility. 53.i understand as an"Owner-Builder°1 am the responsible party of record on the pen-nit. 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. SY,4.1 understand Contractors are required bylaw to be licensed aril bonded iii California and to lisf their license numbers on permits and contracts. 5-t—) 5. i understand if I employ or,otherwiss 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 add federal law.. J /6 !enders#and if l am considered an employer"iunder s#ate and federal law Imus#register with the s#ale and federal government,Mthh61 payroll taxes, provide wo"rkers'.compensation disability insurance, antl contribu#e to unemployment cornpensatrorr for each"employee°!also understand'`my failure#o abide by#hese laws may subject me to serious-firiancial risk. . _.. S (17.1 understand.under California Contractors'State License Laid, an 04vner Builder who builds single-family . residential structures cannot legally build them with the intent to oiler them for safe, unless all work is performed by !i;eased subconai-actors ard the nun her ofstmcfuieoes not exc-ed oGr i r, ri r� by calendar year, or all of the vlork is pei brined under contract with a licensed general building Contractor. l liP.dErs#and as an Owner-Blulld-er if 1 sell the jNOp i y TG;t';''i?IC? I,s r;Z.rrr:"t Is su `d, 1 ir.—F-ba i';e!d liab-f-f r S arty financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction def2cis.in ihe.tvorkmanship or irate-rials. i Ola r�z3z ilr r;Frn;ar ?pip nc nwmE.d G?%1!/1Q t 51b. 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 1-800-329-CSLB (2752)or www.csib.ca.gov for more information about licensed contractors. g p 1' applied for in my name, and understand that 1 10. 1 am aware of and consent to an Owner Builder building ermit a am tha party fag,1 y.and financially responsible for proposed construct on activityat the sife address listed above. agree.:that, as_the partylegally and-financially responsible forth Is,proposed construction activity, 1 will.abide -----------b_y-aiLapphi blelavcsapd_eq��ir m nts.tha.t�Dy-em_Dwner_--Builder_s-as-.w�fLas-eniplo-yers.---- S 12. i agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information.l have provided on this form Licensed contractom are regulated by laws designed to protect_the-public. if you coh�acfwi€>l sOmea-tie wl�o does'nof have a ttcense,-fFre--C"orif-ractors'�tate Lice-isa�8bard-trtay-tse`trhabfe to� --� �- .assist you with any financial loss.you may sustain as a result of a complaint.Your only remedy against unlicensed Contractors may be incivil.court.It is also important for you to understand that if an unlicensed Contractor or :employee of that individual or find is inured white 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. CdhsTRUCTION LENDiNOAGENCY (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 perrnit 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, fortia.notarization, or otherverlficatlon acceptable to the city may required to be presented iwhen the permit is issued . . to i�'er' the roe owner..s signature. Property Owner's Slgnature: :Date: -. (NOTE+:The followfig AuthoAzatian Form,is required to be completed by the properly owtjer only-when desijnathig an agent of the property owner to apply for a itan�t�itction permit for the Owner-Builder). G . AUTHORIZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF i A _ . Fxluding the Notice to Property.Owner,the execution of which 1•understand is my personal responsibility, I hereby autj or J. e following person(s)to act as my:agent(s)to apply for,sign, and file the documents necessary to ob#aln an .O�tii�er=Builder Permit for my project. ScQpe''bf.;i✓ohstrucfion Project(or Description of Work): Protect Location or Address Narpe„of Authorized Agent t< F �� ,_, n i �< Tei fro 1�tT 3�'t at,w i” )u.x?-. '� °} E`tlts 'Address of Authorized Agent Yr i. I declare under penalty of perjury that 1 a�n,3 the'�property c rni?r for the address listed above and l personally Filled out the above'information_and c?rtify its:accuracy:Note.A copy of the propert} owner's driver_`s Incense, form notarizatrdn, or other verif<cation acceptable to the city may be required to be presented when the permit is issued to verily the property owner's signature_ Property Owner's Signature:— --------------- _ Date:.-..--- - Ors�;err'zrild:,For,;a 70.t 0.dnc�Evir--1(1�'/1?/10 Building Department City Of Cupertino ELI] 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: ZQX96 PERMIT# 3 OWNER'S NAME: PHONE# - ­L 0 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of c,"'. no.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