15040228 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 429 CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 15040228
DRIVE
OWNER'S NAME: 20800 VALLEY GREEN DRIVE PO BOX 1368 DATE ISSUED:04/29/2015
OWNER'S PHONE: 4082530200 CARLSBAD,CA 92018 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
APT 429-INSTALL(1)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
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:32609040.429 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 D T 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 ROM L LED INSPEC IO
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 Da
te• L C�
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:
Signature Date All roofs shall be insp ed 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
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 Muni 'pal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Mi05, 5533, d 25534.
Section 3700 of the Labor Code,for the performance of the work for which thisOwner or authorized ager
permit is issued.
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
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.
Signatut /J�il/% yl!��1_ Date ' `
GENERALPIRMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDINGM E P
DIVISION � V
10300 TORRE AVENUE•CUPERTINO.CA 95014-3255 /h�
CUPEFt I`INO (408)777-3228•FAX(408)777-3333•buildino o(�cupertino oro v l v
❑PLUMBINGl misc
❑MECNA1dICAL ❑EEIMISCELLANEOUS
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OWNER NAME G
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CONTACT NAME
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STREET ADDRESS
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CITY. TE,ZIP FAX
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OWE ❑ OWNER-BUILDER ❑ OWNERAGW17 ❑ CONTRACTOR ❑CONTRACTORAGENr ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAME
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COMPANY NAME
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STREET•ADDRESS
CITY,STATE ZIP PHONE
USE OF ❑SFDorDUPLEX. ❑ MULTI-FAMIIY PROJECrINWB,DLAND ❑ YES PROJECT IN ❑I•-.YES IS THEHLDGAN El YES
BUILDING ❑COMMERCIAL - URBAN INTERFACE AREA NO FLOODZONE LI NO
EICHLER HOME? ❑NO
DESCRIPTION OF WORK
111
TOTAL VALUATION:
,:R_CCEiVSD,�B?!- - .>f-_ •;i' _ �'�• ':''.- _ 5-a'.;
By my signature below,I Certify to each of the following-. nerent4 "
or
application and the information I have provided is correct 1 have read the Description ption authorized Work and verify ac!on the
rope a Tee oec's behalf lI have read this r
ordinances it
and slate laws relating to building construction. 1 au tize representatives of Cupertino to enter the above-identifiedpropertyopl with all applicable local
Signature ofApplicant/Agen•- jJjl
inspection purposes.
Date:
SUPPLEMENTAL INF-ORMA I ION REQUIRED _
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-1IERA isc/1pp 2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20800 VALLEY GREEN DR DATE: 04/29/2015 REVIEWED BY: MELISSA
APN: 32609040.429 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 0,Yes E) No PERMIT TYPE:
WORK APT 429 - INSTALL N WASHER & DRYER HOOK UPS
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 113APPLOT 2 # $144
TOTALS: $144.00
r
a_.
Mech.Plan Check 0.0 hrs $0.00 Plawb..l h/ i?t'Ix:c;b Isi c,Plot,
Mech.Permit Fee: 110PERMIT l'laainb..i'er,r;rt Fees: �>lec;..I'ernair 1" r:
Other Mech.Insp. 0.0 L!j 0,ier.P'arn•:r 11F. 2,Li .Inst:.
Uech.Inst=,Ft,0. Pl orV.he,,sp.Fee: Nee hup..l ee..
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 Det for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
Man C`hec .Fee:
PME Plan Check: $0.00
.Permit Free:
Su/pl.
PME Unit Fee: $144.00
PME Permit Fee: $48.00
Construction uc'tion Txx:
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes ) No $0.00
°1%l1'FZ1ZC't'C7 1''lfOd't€Y77£ '
Fees:
Travel Documentation Fee: ITRAVDOC $48.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS.-' $286
50 $0.00 TOTAL FEE $286.50J
50
Revised: 04/01/2015
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
•� 10300 TORRE AVENUE-CUPERTINO,CA 350143255
CUPERTIN01 (408)777-3228-FAX(408)777-3333 •buildino ancuoertino 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: p p rty
SITE ADDRESS
OWNER NAtJIE 2 0�0� ��'�'/�^ � 0 N � APN �� � � E3 P#
2]],,,,NER ADDRESS,/'
- � (�'�.
DESCRIPTION OF WORK: ��`•�
l40 Ac,
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to
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 buildingmake you aware of
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 ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and ial each statement below to signify you understand or verify this information.)
understand a frequent practice of unlicensed persons is to have the property owner obtain an "Ow
Builder"building permit that erroneously implies that the roe ner own labor and m
personally. I, as an Owner-Builder, may be held liable and subject o serious rfina dial risk fong his or r any injuries sustained by
an unlicensed person and his or her employees while working on my pro7perty. My homeowners insurance may not
provide coverage for those injuries. i am willfully acting as an Owner-Builder and m aware of the limits of my
insurance coverage for injuries to workers on my property.
L� 2. I understand building permits are not required to be signed b r
the construction and are not hiring a licensed Contractor to assume this e sponowners sibi) unless they are responsible for
� V3. I understand as an"Owner-Builder'I am the responsible party of record on the permit. I understand that
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 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
y 115. 1 understand if I employ or othenvise 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.
6. [understand if 1 am considered an"employer' under state and federal law, I must register with the state and
federal govemment,withhold payroll taxes,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.
n
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.
(^�8. I 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.
0-1-DuilderFormn 2010.doc revised 04114/10
J_V_u_ I understand 1 may obtain more information regarding my obligations as an "employer'from the internal
Revenue Service, the United States Small Business Administration,the Califomia Department of Benefit Pa
and the California Division of Industria(Accidents. I also understand I may contact the California Contractors'
License Board (CSCR) at 1-800-321-CSCR(27b2)or wwv✓.cslb.ca.d I for more information about ontra Ymtate
contractors, s State
ed
1 am aware of and consent to an Owner-Builder building permit applied for in
my name, and am the party legally and financially responsible for proposed construction activity at the site address listed understand abovthat i
X11. I agree that, as the party legally and financially responsible for this proposed constructionabove.
by all applicable laws and requirements that govern Owner-Builders as well as employers. activity, (will abide
i Z12. i 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 Y property,on our ro erty,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
(DlRECTlONS: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 co
py of roperty owners driver's liense,
form notarization, or other verification acceptable to the city may be required to be presented when'the permit is issued
to veri the ro ert owner's si nature.
Property Owner's Signature:
Date: Z
U
(NOTE.- The foliowing Authorization Form is required to be completed by the property owner only when designatin an
agent of the property owner to apply for a construction permit for the Owner-Builder), g
AUTHORIZATION OF AGENT TO ACTON PROPERTY QWNER'S BEHALF
Excluding the Notice to Property 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
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 Ipersonally filld 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:
O}1:17e1Blcilde1Fo777i_2010.doc revised 04114110