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15060040 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 471 CONTRACTOR:20800 VALLEY GREEN PERMIT NO: 15060040 DRIVE OWNER'S NAME: 20800 VALLEY GREEN DRIVE PO BOX 1368 DATE ISSUED:06/05/2015 OWNER'S PHONE: 4082530200 CARLSBAD,CA 92018 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL F] COMMERCIAL APT 471 -INSTALL(N)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 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:32609040.471 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 DAYS + ED 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 _ granting of this permit. Additionally,the applicant understands and will comply e b 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. I / 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) kr,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE fonstruct the project(Scc.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(x)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,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: � � Date: permit is issued. ` certify that in the performance of the work for which this permit is issued,I shall of 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. Signatu� Date o+.'1 5 `!� , GENERAL:PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•B EP UILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUP511TINO (408)777-3228'FAX(408)777-3333 g MISC ❑PLUMBING ( V ❑MECHANICAL []ELECTRICALMISCELLANEOUS PROIECP ADDRES � - OWNERNAME V. U J PHONE 7,S3-0-zoo �`O�� E-MAIL STREET ADDRESS '2 CITY,STATE.ZIP• FAX CONTACT NAME PHONE E-MAIL STREET ADDRES CI ,STAT$ ZIP L- , FA?C OWNER '❑ OWNER-DU[LDER ❑ OWNER AGENT ❑ CONIRACrOR ❑CONTRACTOR ❑ ARCHITECT ❑ENGIIJEEA ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LTCENSENUMBEA LICENSETYPE Q BUS.LICK COMPANY NAME '�! L E-MAIL STREET ADDRESS F {l f- ed�f✓. CU.STATE,Mr, H NE ARCHITECTIENGINEER NAME LICENSENUMBER BUS.LIC B COMPANYNAME _ E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFDorDUPLEX ❑ MULTI-FAMILY PROJECTINWMDLAND BUB.DING ❑COMMERCIAL ❑ YES PROIECr W ❑YES IS THE BLDG AN ❑YES URBAN INTERFACE AREA ❑NO FLOOD ZONE ❑NO EICHIERHOMEt ❑ND DC•SCRIPTION OF WORK e- TOTAL VALUATION. By my signature below,I certify to each of the following. Iain the property owner or authorized a c' application and the information I have provided is correct I have read the escription of Work M verify it cgro P I-afire omphally w h all a read this local ' ordinances and state laws relating to bui]di conslructio 1 authorize re csentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: — - Date: /�i -/��l- I S'^ SUPPLEMENTAL INFORMATION UIRED ;•,._:::. •'? _ - •-?'OI•FICEa1SEONLXs'`" ':�-'� . • -:w�� .:.. rcoilNrEli,:_=:�� :: Try ;Qt ,.:.AS-'••t'}?....r.!'�ir2!�''••:;``'fin.-q� ti>T•�vQ7�INAJCSAs:w,* ..tU. _..'yT;,�f: MLP -iscApp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20800 VALLEY GREEN DR#471 DATE: 06/05/2015 REVIEWED BY: MELISSA APN: 326 09 040 BP#: *VALUATION: $500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY Multi-Family Dwelling Buildina is PENTA11ATION 1RMAP1 USE: 1 >3 Stories 0 Yes Q No PERMIT TYPE: A WORK APT 471 - INSTALL N WASHER & DRYER HOOK UPS SCOPE Mech.Plan Check 0.0 hrs $0.00 lll.wib.llhw(.J1eck- Mech.Permit Fee: 1MPERM T /"tar,�n..7'erralit I £: Isl£f:.Permh Other Mech.Insp. 0.0 hrs $48.00 Or/1er.P'lt,'nb Irrsp. t?t.'a£r1 71<<:.Inr};. El� Meek h7sp.I`c'e: Itlsi Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitmy Sewer District,School District,etc. . These,fees are based on the prelinfinar information available and are only an estimate. Contact the De t or addn'l into. FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 �2 # Mechanical Suppl.PC Fee: ) Reg. 0 OT f 0.01 hrs $0.00 $144.00 IBAPPLOT Other Appliance/Equip PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee:Q Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $48.00 C onstru timi Zcrx: Administrative Fee: 1ADMIN $45.00 0 Work Without Permit? 0 Yes (F) No $0.00 G Advanced Planning Fee. $0.00 Select a Non-Residential G Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure 0 i Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $142.50 $144.00 TOTAL FEE . $286.50 Revised: 05/07/2015 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION L9 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 CU P ERTIN O1 (408)777-3228 o FAX(408)777-3333 -buildinona cuoertino oro 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 ® APN 6 Q e BP(,x)46 6 V60 OWNER NAME OWNER ADDRESS 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 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 (D1REC710NS:Please read and ins!each statement below to signify you understand or verify this information.) 5 V1. I understand a frequent practice of unlicensed persons is to hav Builder"building permit That erroneously implies that the roe a the property owner obtain an "Owner- his or hr own laor and personally. I,as an Owner-Builder, may be held liable and subject o serious r is prfina cial risk foreany injuries sustainedmaterial 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. J ld 2. 1 understand building permits are not required to be signed by propeo thwners e construction and are not hiring a licensed Contractor to assume this s resports b lily unless they are responsible for U3. I understand as an"Owner-Builder' I am the responsible party of record on the permit. understand protect myself from potential financial risk by hiring a licensed Contractor and having the perm t filed'nh s orhher may name instead of my own. LV4. I understand Contractors are requirbd by law to be licensed and bonded in California and to 1 numbers on permits and contracts. list their license 5 i understand if !employ or othen�vise engage any persons, other than California licensed Contractors,and the otal value of my construction is at least five hundred dollars ($500), including labor and materials, I ma be considered an "employer"understate and federal law. Y n 6. i understand if I am considered an"employer"under state and federal law, I must register with the state and federal government,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. J7. I 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. -A i understand as an Owner-Builder if 1 sell the property for which this permit is issued, I may be heldlale for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. DaneiBiuilderFornt 20)0.doc remised 04114110 -g: 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 PaY me License Board (CSLB) at 1-800-321-CSLB(2752)or www.cslb.ca.gov for more information about licensed nts, and the Califomia Division of Industrial Accidents. I also understand I may contact the California Contractors'State contractors. S160- I am aware of and consent to an Owner-Builder building permit applied for in my name, am the party legally and financially responsible for proposed construction activity at the site address listed abo a that 1 11. I agree that, as the party legally and financially responsible for this proposed construction by all applicable laws and requirements that govern Owner-Builders as well as employers. activity, I will abide 12. 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 heublic. if Y unable to You contract with someone who does not have a license, the Contractors'State License Board may be u p assist you with any financial foss 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 workingon our property, for You obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible fortiable verifyingdwhether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (D1REC770NS: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 the property owners driver's cense, form notarization, or other verification acceptable to the city may be required to be Presented when'the permits issued to vert theproperty owner's si nature. Property Owner's Signature: Date: s�l ---------------------- ------------------- -------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when desi natio an agent of the property owner to apply for a construction permit for the Owner-Builder). g g 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 fo 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: O17+17e!B1lildel F07T17_2010.doc erised 04/14/10