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14100126 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 477 CONTRACTOR:VALLEY GREEN DRIVE PERMIT NO: 14100126 OWNER'S NAME: VALLEY GREEN DRIVE P O BOX 1368 DATE ISSUED: 10/21/2014 OWNER'S PHONE: 4082530200 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ UNIT#477-WASHERIDRYER HOOK UPS License Class Lie.# 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:32609040„vO 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 A P IT 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 DAYVS, LED 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 CO Z granting of this permit. Additionally,the applicant understands and will comp ied 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. 25 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, 5 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,Sections 25505,25533,an 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ageDate:la-21-1-f permit is issued. t-52�iA e I certify that in the performance of the work for which this permit is issued,I shall J 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 Cupertino Municipal Code,Section Licensed Professional 9 18. Sign - Date Zl'lam GENERAL:PERM tT APPLICATION COMMUNITY DEVELOP MEP DEVELOPMENT DEPARTMENT•BUILDING DIVISION ` O 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 \O CUPERTINO (408)777-3228•FAX(408)777-3333•buildinc0cupertino.ora \�\+ M �SC ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL DMISCELLANEOUS PROJECT ADDRESS A1 APN H 39z 6 eq 4 OWNERNAME PHO E-MAIL S - STREET ADDRES�� Cll' STATE,ZIP. CONTACT NA _ E-MAIL STREET AnnRFCC•2-0 p /� r^t cTaTF_ ZIP er) KCO: ER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT ACTOR NAME C LICENSENUM � LICENSETYPE /� BUS.LICK COMPANY NAME ^ D E-MAIL L FAX l L STREET DDRESS STATE,ZIP PHONE �r c ARCHITECT/ENGINEERNRME LICENSE NUMBER BUS.LIC H COMPANY NAME E-MAIL FAX STREETADDRESS CITY,STATE ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WO.DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUMDTN..Q ❑COMMERCIAL 'URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION 0F�WORK TOTAL VALUATION: Y By my signature below,I certify to each of the following: I am the property owner or authorized agent to owner' f. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is urate. I age comply with all applicable local ordinances and state laws relating to building construction. 1 tl1 rize representatives of Cupertino to enter the above-idrohff led property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMAY10N REQUIRED k 4❑ OvE, THECOUI`r{SR. EXPRESS c I . :�, ❑`STANDARD r• r _ � I y • i, � ❑.LARGIa• � MEPA&Mpp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 20800 VALLEY GREEN DR DATE: 10/21/2014 REVIEWED BY: MELISSA APN: 326 09 040 BP#: *VALUATION: $500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMIT TYPE: 1 RMAP WORK UNIT#477-WASHER/DRYER HOOK UPS SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 113APPLOT 2 # $144 TOTALS: $144.00 f, 1 Mech.Plan Check 0.0 hrs $0.00 I'iufrb.Pisan Check- I <:.AC"'r',£:£;kIF I Mech.Permit Fee: IMPERMIT f'?tar t.I'ez;raiz l"£:£:: Ehec..I'£rnwil , t:: Other Mech.Insp. LA hrs $48.00 Otta r 1'rarm b Ir sr), Ot/;:a t;i.;:.I I;. Ll ,Ife:ch, fmj.f. I`c'e: Phort,A,,sr?—Fee, lsiecr:. hff,.F,66. 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 prelimina information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS Sapp[ PC'Tee PME Plan Check: $0.00 PME Unit Fee: $144.00 PME Permit Fee: -71 $48.00 C,csrr rprtcr`aatrz fUX: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes 0 No $0.00 Travel Documentation Fee: 1TRAVDOC $48.00 i Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 F $286.50 $0.00TOTAL FEE: $286.50 Revised: 08/20/2014 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228 FAX(408)777-3333•_buildinona cuoertino ora 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 specified at: SITE ADDRESS (,/f �/ OWNER NAME G1� / ` AP � © ©�1 BP# l 1 W V O NE�annpES �ne� a 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 tows 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 ACKNOWLEDGMENT AND VERiFIGATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 5�1. 1 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 or her employees while working on m y property. My homeowner's provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of thelnsurance limits of myay not insurance coverage for injuries to workers on my property. 2. 1 understand building permits are not required to be signed bproperty the construction and are not hiring a licensed Contractor to assume hiresponsibility. owners unless they are responsible for .5 J 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I ma protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her y name instead of my own. 4. 1 understand,Contractors are required by law to be licensed and bonded in California numbers on permits and contracts. and to list their license )/ 5. i understand if i employ or otherwise engage an total value of my construction is at least five hundred dollars rt ($500), including labor and her than California licensed I may bes,and the considered an"employer"under state and federal law. 5JL6. 1 understand if I am considered an"employer" under state and federal law, i must register federal government, withhold payroll taxes g ster with the state and P Y ,provide workers'compensation disability insurance, and contribute to unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 1/ 7. 1 understand under California Contractors'State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. -V 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. Oiti,neiB:nldeiFor7n 2010.doc remised 04114110 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 1-800-321-CSLB(2752)or www.cslb.ca.gov for more information about licensed contractors. 5 V 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. VY-1 1* I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. :F�_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 laws designed to protect the public. If you contract with someone 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 employee of that individual or firm is injured while 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. CONSTRUCTION LENDING AGENCY (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 permit can be issued,this farm must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A co py of the property 's form notarization, or other verification acceptable to the city may be required to be pr sentedownere when the permit,is Issued to veri the Dronprfvowner's signature. Property Owner's Signature: Date:_1l' - Z/--1--/ (NOTE: The following Authorization Form is required fo be comp/efed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZAT[ON OF AGENT TO ACTON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I 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 Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: Ox.-7ieiBuildeiFonn_2010.doc revised 04/14/10