13110173 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR CONTRACTOR:MORROW-MEADOWS PERMIT NO: 13110173
CORPORATION
OWNER'S NAME: 20800 VALLEY GREEN DR 1050 BING ST DATE ISSUED:11/26/2013
OWNER'S PHONE: 4082530200 SAN CARLOS,CA 94070 PHONE NO:(650)634-0682
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
II
License Class Lic.# UNIT 487-WASHER/DRYER HOOK UP
Contractor Date
I hereby affirm that I am licensed under theprovisions of Chapter 9
(commencing with Section 7000)of Division 3 1.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:32609040.00 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 M LAST 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 llp0k,12
granting of this permit. Additionally,the applicant understands and will comply Issued 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.
C;- v 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)
�+ as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
J 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,Sectio s 25505,25533,a 25534. 3
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent /
Date: —/
permit is issued.
SL1 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 regulationsper th upertino Municipal Code,Section Licensed Professional
9.18.
Signature Date,
C 0 i',J.S T R U C T 100 P E F,110 if PT L 1C,-A.T 10 N
CON411AIUN TY DEEVE1 OF1'-,,'-`!T DE.7'.FT'A:-',F- DiNG
10300 TO RFZE AV=N`U`
(408)777-3228 - FAX(408)777-3-133-
C U I N a
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DESCRIPTION OF WORK
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PRE-APPLICATIOIT -iEs
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By-'
y signature
below I certify to each PFt-Y.9;�7er or authorized agent to act on the property ovmer°s behalf I fiave read flus
application
-PPke B94?1ving; property
the
information bf WoYk and verify rt is accurate I agree to comply with alI applicable local
ordinances and state laws relating t1bildffig"con' --� - .". - t
Ciiperttno to enter the above identified property foruispectron purposes
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INFORMATION REQ
s
SIM Ormmdg
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required- - -,tb i§sd-mice
permit for ziew
gi
ominercial 13ldgs. Provide completed- .Hazardous-MaLej�al
sDisclosuz--
10m If any jjazard6ils
Copy of Fla=in-Approval L---iL--r Dr Meeting with Plarmira.gprlor to
-ubiii:-L�al ofBi-liEldin ap I
plicaton.
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20800 valley green dr.#487 DATE: 11/26/2013 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $500
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1 RMAP
USE: PERMIT TYPE:
WORK Washer/Dryer hook u
SCOPE
yz"a _.
Mech.Plan Check 0.0 hrs $0.00 f'hwd',-Plan,0 ic!k I'rr
Mech:Permit Fee: 1MPERMIT t'trF;n .I'zr,rrr.P I ::
Other Mech.Insp. 0.0 hrs $47.00 olhf,,,.r-°hw,<h Insp.
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These fees are based on therelimina information available and are only an estimate. Contact the Dept-for addn'l info.
FEE ITEMS (Fee Resolution 11-.053 L; . 71113j FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 �2 # Mechanical
Supp/.PC Fee: Q Reg. OT 0.0 hrs $0.00 $140.00 IBAPPLOT Other Appliance/Equip
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-(j) Reg. 0 OT ro,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
Administrative Fee: IADMIN $44.00 0
Work Without Permit? Yes Q No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure 0
i
Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
' P6%NUM ir
ALS : $139.50 $140.00 TOTAL FEE: $279.50
Revised: 10/01/2013
i
OWNIER-BUILDER DER DISCI O'zU.;� i
i COf��MUN i 1' =V=�O✓! =N i =, i�.iB;�i 3LiL iliG Ci' i�IOiv
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
CUPERTIPiO (408)777-3223. FAX(408'777-3333 • buflding,,5c oa ina.oro
_
Dear Property Owner(s):
-An application for a building-perinlfhas-been submitted in-you'r-hame listing yourself as the.builder.of the proper'�y
--------improvements-spm c-
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SITE ADDRESS lj&lleosEf AP
D �D`
NAME OW
D BPS
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OWNER _ _ - . � _._... . ... .._ __ __.. i`1ER-ADQRESS"....:..k�T l
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DESCRIPTION OF WORK,
We are providing you with an Owner-BullderAcknowledgment 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 o€ficiat 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 ACKNOWLERWENT AND VERIFICATION OF INFORMATION
(DIIRECTiONS.Please read and initial each statement below to signify you understand or verify this information.)
�J 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Buildel"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 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.
V2.t understand building permits are not required to be signed by properly owners unless they are responsible for
th�e/ construction and are not hiring a licensed Contractor to assume this responslbllify.
3 V 3.1 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.
c5 it•X1.1 understand Contractors are required by to be licensed and bonded iii Califomia and to fist their license
nu,/m'bers on permits and contracts.
s 1� 5. 1 understand if 1 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 fabpr and materials,1 may be
considered an"employer"under state and federal law..
�` 6 I i.inderstand rf!am considered an°employer"under state arid federal law, l,must register with fhe state and
federal governmerifr.ivi#hfioldpayioll taXes, provide workers'compensation drsabiltfy Insurance, and contribute to
unernpioyment compensatroll for each"employee" i also understand. far[ure to abide by these laws may subiect
:.
me.oserious fiinancral risk.
S!" - 7.1 understand.under Callfomia Contractors'State License l_aw,an 04vner Builder who builds single-family .
residential structures cannot legally build them with the inient to o;ler them for sale, unless all work is performed by
licensed subcon:i-actors and the number of strucfures doas n b t exceed a_r V'ri't 11111 any calendar year, or all cf the vvor;k
is performed under contract with a licensed general building ConI0actor. II
o..f understand as an Owner-Bui1dBriF se 1 lite prop.i y for , IciZ LiZ!u r :rrr'r is 'sL'
I 1' C ay Ii'
any+nand2l of personal injuries sustained by any subsequent own er(s)that result from any latent construction i
defects-fn the workmanship or materials.
i
Olt rsez_�� A, or;;r X010 doc n= tsc>d 0?/t /IO .
I
�m 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 Senent Payments,
and the California Division of Industrial Accidents, I also understand I may contact the California Contractors'State
i,icense Board(CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed
co9n/tractors.
Sid 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 responslble for proposed construction activity at the site address listed above.
11. I agree tifine par)ydegally and financially responsible for this-proposed construction activity, i wiU abde
.p1Lcabli�Lla #h6A(hdi-Build .rs a�w ILas_emplD�Ce�s_ _
V 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 bylaws designed to,protect the public If
—�- _- `you contract w someone w o doeano ave a icense, ttie�Con tors ate Lice se--BoardTTT-ayt-�-unabre.fo-
-,assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors maybe in clyil caurt`It is also important for you to understand that if an unlicensed Contractor or
,employee`of that individ'uat or firm is injured while working on'your property;you may b'e 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.
COI&STRUCTION LENDING AGENCY
(DIRECT/ONS: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.)
:r
i 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/icense,
form.notarization, or other verification acceptable to the city ma be required to be presented when the permit is issued
to verify the ro er owner's signature.
Property Owner's Signature: Date:
---------------------- ------ ---•-- -=----------- =--------------=-------------=----=-----------=---------- ---=--------=----------- -
(NOTE The fo/%wrngAuthorization Form is required to be completed by the property owrjer only when designating an
agent of the property owner to apply fora'construction permit for the Owner-Builder).
AUTi HORiZATION OF AGENT TO ACTON PROPERTY OWNER'S BEHALF
Exi lading the Notice to Pro*perty.Owner,the execution of which 1•understand is my personal responsibility, I hereby
authorize„the following person(s)to act as.my:agent(s)to apply for, sign, and file the documents necessary to obtain an,
&tN erBuilder Permit for my project. ;
Scope of Construction Project(or Description of Work):
Proleci Location or Address:
i
Name of Authorized Agent i Tel No
Address o: utho.rized Agent
.. _ :.:n. {. -i-t h Y..�- A l nor nth til d-fir rt trFie.
I deGlarc ilridc� Pena lly of perjut� that i a•n the property owner for ti ie address listed a u and r Nom. Svr��..,ry
above inforrnatioh_and certify its accuraey Note:A copy of the propzrty oy✓ners drivers license, form notanzatron, or other.
verification acceptable to The city maybe required to be presented when the permit is issued to vent'the propery owners
signature.
Property Owner's Signature: Date:
Or-;e�3uzlde Foran �OIO.doc revises OT/14/IO