13100201CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 292
CONTRACTOR: KORET
PERMIT NO: 13100201
FOUNDATION/UBS
OWNER'S NAME: KORET FOUNDATION/UBS
20875 & 20990 VALLEY GREEN DR
DATE ISSUED: 10/29/2013
OWNER'S PHONE: 4082530200
CUPERTINO, CA 95014
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
❑ LICENSED CONTRACTOR'S DECLARATION
APT # 292 - WASHER & DRYER HOOK UPS
License Class Lic. #
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
Valuation: $500
performance of the work for which this permit is issued..
Sq. Ft Floor Area:
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: 32609041.292 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_P RMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
1 CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
ed b 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:
Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
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,
usiness & Professions Code)
!,
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
the
JZ,
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of
Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
California Health & Safety
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
declarations:
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
defined by the Bay Area Air Quality Management District I
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
performance of the work for which this permit is issued.
the Health & Safety Code, Sections 25505, 25533, and 534.
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
Owner or authorized agent ate f -Z1,
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code, must
work's for which this permit is issued (Sec. 3097, Civ C.)Lender's
forthwith comply with such provisions or this permit shall be deemed revoked.
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 t e Cupertino Municipal Code, Section
Licensed Professional
9.18.
- Date l� " L9' �L
Signator
K
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CONTRACTORNAMS- LICENSE NUMBER "LICENSE TYPE BUS. LIC L 'M�3 c:t---o-- -1 2-
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IARCIUTECTIENG11, NAME LICENSENUZMEP, BUS. LIC #
COMPANYNAME E-MAIL FAX
STREET ADDRESS C==, STATF, ZIP PHONE
DESCRIPTION OF WORK
11,011A /,//-)
EXESUN ci USE01POSEWE
PROPOSED CONSULTY-PE #S
STORIES S
.
-=STG NEVfRDOR DEMO TOTAL
AREAAREA AREA NETAREA
BATBROOMdK OTHER
REMODEL AREA ,REMODEL AREA
, '
PORCHAREADECKARhA.TOTALDECrFQRCIAREA..� CEAREA-'❑ DET
.ACH
ATTACH
UNITS: IS A SECOND UGIT YES SECOND STORY YES
j NO ❑NO
PRE-APPU-nciYES IFYES.PROVDECOPYOF PLANI�SNA&T-
,
PLANNING APPLI PLANNING APPROVAL. LEITER
By my signature below, I certify to each 6fthe following:, I a m the property owner
'
and the information lhave'�iovidqd is correct. I have read th� D cpptiono Work
' ' fW
rj4cation
ordinances
ances and state la�is olating to build- cDnstrucl��IauthoIrizer isentatiyesofCup . ert
0
..�Iinature 6fA�! 5,
Plican't1A'kent:::'.--el
S
OR
New SFI)�Qt lro,
s:- Apply for demolition pe- ,
r
buffiEng(s), DchaoEtioa Acquired prior to issuanco ofbuil clLug
permit for new building.
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v
Comrnercial Bldgs: Provide a completed Hazardous -Mfac---,1s
if aTy ETL-=-do---,S arz! 'Ft::— aS I
F
Co TCT ig
verify it s accurate. I agree to com
to. enter the 66ve-identified proper
CITY OF CUPERTINO
UV Ti c'TTMA'TnR _ RITII.DIN(: DIVISION
APPLIANCE / EQUIP TYPE
j'1/1% 1'J IJ 1111Lis
--
QTY
UNITS
ADDRESS: 20975 VALLEY GREEN DR #292
DATE: 10/29/2013
REVIEWED BY: MELISSA
lia
Ot"w" k>ler, IMP
2
*VALUATION:
$500
APN: 326 09 041.292
BP#:
Sl//)rl/. hisp Fee
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
PME Unit Fee:
PENTAMATION 1RMAP1
SFD or Duplex
$47.00
PERMIT TYPE:
USE:
WORK I
APT # 292 - WASHER & DRYER HOOK UPS
$44.00
SCOPE
$0.00
APPLIANCE / EQUIP TYPE
FEE ID
F'ltonlh. Plan Ch1,r.k
QTY
UNITS
BP FEES
F-Iec Pe1,n,l Vcc
Other Appliance/Equip
113APPLOT
Ot"w" k>ler, IMP
2
#
$140
Sl//)rl/. hisp Fee
PME Unit Fee:
$140.00
PME Permit Fee:
$47.00
Construction Tax:
Administrative Fee: 1ADMN
$44.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS-
Travel Documentation Fee: ITRAVDOC
$140.00
Strong Motion Fee: IBSEISMICR
NOTE: This estimate does not include fees due to other Departments y e. reammng, lame r• 1 11-,��••--� - - — - -
,.:�..Ll..--.4...., o., ..amato_ Cnntact the Dent for addn'I into.
District, etc). These fees are based on the prehminar
FEE ITEMS (Fee Resolution 11-053 E(t 7/1713)
Mech. Plan Check 0.0 hrs $0.00
F'ltonlh. Plan Ch1,r.k
hl«n Ch,,,(�k
Mech. Permit Fee: IMPERMIT
Plrunb. Pcv nik Vcc
F-Iec Pe1,n,l Vcc
Other Mech. Insp. 0.0 f�j
2::�j1_h��°.
Other Plumb Ince,
Ot"w" k>ler, IMP
;1J�•<{z lras/z 1•ee'
_ _
/';trnr./�. ir;ap. (<,�,:
�• .,. ___:-__ n..Lr:- TIZ
l>1<zc. Ins/,. /•��e
-/. C.., c,..,;t,.n�.cowor Metrict-School
NOTE: This estimate does not include fees due to other Departments y e. reammng, lame r• 1 11-,��••--� - - — - -
,.:�..Ll..--.4...., o., ..amato_ Cnntact the Dent for addn'I into.
District, etc). These fees are based on the prehminar
FEE ITEMS (Fee Resolution 11-053 E(t 7/1713)
in urrauuun ..��.•��•�
FEE
�••� »•
QTY/FEE
�•-- _____-____- _ _
MISC ITEMS
Plan Check fee:
.S'rrp/)1. PC" FCC
PME Plan Check:
$0.00
Sl//)rl/. hisp Fee
PME Unit Fee:
$140.00
PME Permit Fee:
$47.00
Construction Tax:
Administrative Fee: 1ADMN
$44.00
Work Without Permit? 0 Yes 0 No
$0.00
'I dl'unce Planning 1`ecs:
Travel Documentation Fee: ITRAVDOC
$47.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$279.50
$0.00 TOTAL FEE:
$279.50
meviseu. iviv i/cu ij
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�_ J__0 . -NT ; 1T A _iNT .� i1L-iNG Di'4 10
COr4 !JJ �iT
10300 TORREE AV E NU- • CU-RTINO, CA 95014-3255•
CUPERTINO (408) 777-3223 • FAX (408J1777-33-33 • ��;idina cos _;no.or
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-speeified•ac-
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 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 ACKNOWLED.dMENT AND VERIFICAT{ON OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this informiafion.)
�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 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.
J/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 responsibility:
3.1 understand as an "Owner -Builder" I 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.
j 4.1 understand Contractors are required by to be licensed and bonded In California and to fist their i'icense
numbers on permits and contracts.
�5. 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.
i� 1 6.1 understand if I am considered an "employer" understate and federal f "imust.reglsi. 4 with the state and
federal government, withhold payroll taxes, provide workers' comperrsation dlsablltty insurance, and contribute to
unerr?pfoyment compensation for each "employee.° ! also'understand my failure to'abide_ by these laws iiaysubject
me to serious financial risk. _ . ,
51/-7.1 understand. under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them v itis the intent ;o offer them for safe, unless all work is performed by
! ;en5ed subcl.nu-=CtoT> and the number of str[Jcfm-Gs, docs in0t /c. -ed o-. NJ !hin Pw C31-ndar y'P?r, or all cf the v,,oi <
is perf"ornled und�'r contract wiiil licensed g nsral buildin(J Cc•n') ctor.
: i
3. 1 understand as n Owr8r-i uild r is 1 „c;l ! C(0+ --i `., 1G L'r.'1Cit U . i:=:�.T:1'J ._� '.:LI l in c1'
r y flriancial or personal fijurIes sustained by ml sl.rbs quant a�Jnsr(s) --mt result from any latent consiructir�n
defect fn the 4vorkmgnsnip or lll`dt 'ri l
Ox:;rr 3cr1�'�;Fm:�n-'010.�'ocn-iz,rdG2/(!L!"0
5V 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.
10. 1 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.
51` 11. 1 agree that, as the party.legally and,financially responsible for this proposed construction activity, I will abide
.by_aflapplicabteJaws-and requirements.that..govern-Own er_Budders-aswelt-as employers— _______-__-__.
3 �/ 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information 1 have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
:you confracf witfi someorfe 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
pemployee of that individual or firm is injured while working on your property, you may bb 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
i ose Contractors are properly licensed and the status of their workers' compensation insurance coverage.
r •
CMSTRUCTiON LENDING AGENCY
(D7 TECTIONS: 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 properly owner's driver's license,
form. notarization, or other verification acceptable to the city may be reguired to be presented when the permit is issued . .
to Verify the property owner's signature.
Property Owner's Signature: %fes t) Date: le7.2 e
,t. v
(NOTE. • The following Authorization Form is required to be completed by the property owrjeron/ywhen designating an
agent of the properly owner to apply for a- construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACI" ON PROOERTi Y OWNER'S BEHALF
Exbluding the'Notice' to Property. Owner, the execution of which 1 understand is my personal responsibility, l hereby
authorize the following person(s) to act as.my:agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner`-Bulider Permit for my project.
Scope of Cohstruction Project (or Description of. Work):
Signature.
P6)perty
ignatur-e-
Property Ok.vner's Signatr�re:
Date:
01 t.)?IrRuzJdsrio r; a 2010.doc,E1,s -1,0V1-'i0