15030010CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR
CONTRACTOR: 20800 VALLEY GREEN
PERMIT NO: 15030010
DR
OWNER'S NAME: 20800 VALLEY GREEN DR
PO BOX 1368
DATE ISSUED: 03/02/2015
OWNER'S PHONE: 4082530200
CARLSBAD, CA 92018
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
❑ LICENSED CONTRACTOR'S DECLARATION
APT 468; 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:
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
the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM L ALLED INSPECTION.
upon
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the Issued by Dat . Z
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
918. 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 Date:
Signature of Applicant:
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,
do the work, and the structure is not intended or offered for sale (Sec.7044,
will
Business & Professions Code)
I, as owner of the roe y g HAZARDOUS MATERIALS DISCLOSURE
property, rty, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
Health & Safety Code, Sections 25505, 25533, and 25534. I will
SI
California
hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
hazardous
declarations: Health & Safety Code, Section 25532(a) should I store or handle
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
with the Cupertino Municipal Code, Chapter 9.12 and
performance of the work for which this permit is issued. will maintain compliance
I have will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sectio 25505, 25533, an 5534.
and
Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent Date: 2 l'
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 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, I must
work's for which this permit is issued (Sec. 3097, Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked.
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
918.
Date
Sign'
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION (�o
p MEP
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (�v
CUPE117'INO (408) 777-3228 • FAX (408) 777-3333 - building(cDcupertino.ora MISC
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OWNER 11 OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAME 11
LICENSENUMB
LICENSETYPE
BUS. LIC # .
COMPANY NAMV�"' -,®
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ARCHITECT/ENGINEER NAME
LICENSENUMBER
BUS. LIC N
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY
PROJECT IN WI-DLAND ❑ YES
PROJECT IN
❑ YES
IS THE BLDG AN YES
BUILDING: [3 NE
'URBAN INTERFACE AREA ❑ NO
FLOOD ZONE
❑ NO
EICHLER HOME? ❑ No
DESCRIPTION OF WORK
TOTAL VALUATION:
RECEIVED B
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prop
's behalf. I have read this
application and the information I have provided is correeL I have read the Description of Work and verify it is accurate. i agree to comply with all applicable local
ordinances and state laws relating to buildin construction. I authorize re esentatives of Cupertino to enter the above-identificd property for inspection
Signature of ApplicanUAgent: Date: i�
purposes.
SUPPLEMENTAL INFORMATION UIRED
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MAJOR.-... 7.ti
MEPMisc✓Ipp 2011.doc revised 06/21/11
� CITY OF CUPERTINO
I FEE ESTIMATOR — BUILDING DIVTCTCIN
Y
ADDRESS:-WAI,164i� - -ATE: _
REVIEWEDBY:
I'Furr :';:r=rt:
APN: '3L el
BP##:
*VALUATION: $500
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
$0.00
PENTAMATION
PERMIT TYPE: 1 RMAP �
WORK
washer/dr er hook u
SCOPE
$0.00
.V1- 1 nIa esuinuie does nor inctuaeJees aue to omen Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the Drefindnarir in Mrmation available and are onl an estimate Contact the D t
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
Mech. Plan Check 0.0 hrs $0.00
1.11uwb, Al"'w,
I'Furr :';:r=rt:
Mech. Permit Fee: ]MPERMIT
I'it�r-�/�. l'r rr>;:;. c�:
!"
tt
Other Mech. 0.0 hrs
Insp. $48.00
; >
his
$0.00
I rd7..lt'ee.'
$0.00
.V1- 1 nIa esuinuie does nor inctuaeJees aue to omen Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the Drefindnarir in Mrmation available and are onl an estimate Contact the D t
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
FEE
QTY/FEE
e or ar n ur n.
MISC ITEMS
Plan Check Fee:
$0.00
= # Mechanical
$144.00 ]BAPPLOT Other Appliance/Equip
Suppl. PC Fee: (D Reg. 0 OT0.0
his
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
O.0
hrs
$0.00
PME Unit Fee:
$0.00
Permit Fee:
$48.00
/PME
i.,t)s'Z,CiI•Ii�"ifi.3ft..£ £{moi'..
Administrative Fee: ]ADMIN
$45.00
0
Work Without Pennit? 0 Yes) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential Q
Building or Structure
A
Travel Documentation Fee: 1TRAVDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALSr
$142.50
$144.00 TOTAL FEE:
$286.50
Revised: 08/20/2014
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228' FAX (408) 777-.3333 - buildino0cuoertino 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:
vve are proviaing 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.
DIRECTIONS:Please read and initial each statement below 11sl signify v'AI RJN
g you understand or verify this information.)
1. I understand afrequent practice of unlicensed persons is to have the property owner obtain an "Owner-
uilder" building permitthat 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 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. ! understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
53. 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.
1.l_14. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
:�L/5. i understand if I employ or otherwise engage any persons, other than California license
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.
_6. I understand if I am considered an "employer" under state and federal law, i must register with the s
federal govemment, withhold payroll taxes 9 tate and
nsurance, and contribute to
unemployment compensationforeach "employees also understand my failure to�bide by these laws may subject
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 with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed fourwithin any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
V8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
a y financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
ON71e1BUildelFO171t_2010.doc remised 04114110
4' � L9: 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 (2782) or www.cslb.ca.gov for more information about licensed
contractors,
,�IZ10. I am aware of and consent to an Owner -Builder building
n my name, and understand
am the party legally and financially responsible for proposed construction perit aactivity atlied for �the site address listed abo ethat f
�✓ 11. 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.
J_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 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 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,
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 sianature
Property Owner's Signature:
Date: -t/ 7/, j`
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE. The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON 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:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that l 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:
Oi+alei Builder Forna_1010. doc revised 04/14110