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15110008CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR UNIT 201 CONTRACTOR: KORET VC I LP PERMIT NO: 15110008 OWNER'S NAME: KORET VC I LP 611 FRONT ST DATE ISSUED: 11/02/2015 OWNER'S PHONE: 4082530200 SAN FRANCISCO, CA 94111 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL 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 Sq. Ft Floor Area: Valuation: $�00 performance of the work for which this permit is issued. 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: 32609041.201 Occupancy TN pe: 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 FROM 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 J� Issued by: �r�✓, TI �}% Date: ��-� •� 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 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. ❑ 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. 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 1 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, S . s 25505, 25533, d 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized a nt: Dat �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 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 ie Date— GENERAL:PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT s BUILDING DIVISION 10300 TORRE AVENUE • CUPERTIMO, CA 95014-3255 Am CUI'5rtTINCa (408) 777-3228 F=AX (408) 777-3333 • building a(7cupertino ora d ❑ PLUMBING ❑MECHANICAL ❑E-LECTRICAL PROJECT ADDRESS ❑ MISCELLANEOUS OWNERtdAME�� ' L [ �v�?7 ZC/ l APNif 3� �' C �p _ _ li \ C l �j �1 PHONE EMAIL STREET ADDRESS � Y t0 oZ S�—CI.�Cf 1 L L (/� !y"C ' j fir' /j CITY• ST ZIP. �/ �C FAX ��' CONTACT NAME AGENT ❑ ACH7CT EG STREET ADDRESS % r PHONE e2 b TOTAL VALUATION: By my signature below > I certify to each of the follOwing. I am the property owner or authorized agent to act on the ro4crtY :...a_ application and the information I have provided is comrL I have read Ile Description Of Work and verify it is accurate. I agree ro comply with all applicable Y ordinances and state lays relating to buQding const coon. I authgriz rcpresentativcs of Cupertino to enter the above -identified prop bchal£ ]have read this pP c local Signature ofApplieant/Agent: ,� " `� P Percy for inspection purposes Date: SUrPLEMENTAL INFORMATION OUIR FTI -Ad PdliscXpp 201), doc revised 06/21 /l I ' L [ �v�?7 CITY, AT_ ZIP FAX OWNER ❑ OWtJ-eR-BUA DER ❑ O c� AGtZdI ❑< CONTttAC'rOR ❑ CONTRACTOR AGENT ❑ ACH7CT EG ❑ DSCONtRACORNAME v2Lop8R C3 TENANT rd COMPANY NAME �' =S LICENSE NUMBER /� j� 7 E-MAIL LICENSETYPE ( BUS. L[C rf Jr ? _ ? F STREET ADD ESS , .�' �/< ,• CXY. STATE. ZIP /-7 C HONE ARCHITECTJENGINEERNAME LIC ENSENUhIBER J COMPANY NAME - BUS. LIC 9 E-MAIL _ • STREET ADDR'cSS - . FAX ' CITY. STATS ZIP USE OF ❑ SFD arDt1PL -=-n-FAhffLY I PHONE BUILDING.- ❑ COMh¢RCIA PROJECT IN Wft DLAND ❑ YES URBAN INTERFACE AREA PROTECT W ❑ YES ]5 THE BLDG AN Q DESCRIPTION OF WORK NO FLOODZONE ❑ NO EICHLER HOAfE7 Y)s Q No - TOTAL VALUATION: By my signature below > I certify to each of the follOwing. I am the property owner or authorized agent to act on the ro4crtY :...a_ application and the information I have provided is comrL I have read Ile Description Of Work and verify it is accurate. I agree ro comply with all applicable Y ordinances and state lays relating to buQding const coon. I authgriz rcpresentativcs of Cupertino to enter the above -identified prop bchal£ ]have read this pP c local Signature ofApplieant/Agent: ,� " `� P Percy for inspection purposes Date: SUrPLEMENTAL INFORMATION OUIR FTI -Ad PdliscXpp 201), doc revised 06/21 /l I CITY OF CUPERTINO FEE ESTIMATOR - 81111,nINC: n1V1Q1nN IlaADDRESS: 2,W LLEY GREEN DR ZUI DATE: �f-t- I — REVIEWED BY: MELISSA UNITS APN: to © 4 f BP#: 'VALUATION: $500 —71 PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Multi -Family Dwelling USE: Building is >3 Stories Q Yes Q No PENTAMATION PERMIT TYPE: 1 RMAP1 WORK UNIT ;o'a /INSTALL NEW WASHER/DRYER HOOKUPS SCOPE Suppl. InsIg Fee APPLIANCE / EQUIP TV'PE FEE ID 1'111t„i'. Plan Chi : QTY UNITS BP FEES F- c. Perinii Fec i Other Appliance/Equip 1BAPPLOT . ­ tiiherElec Insp. 2 # $144 NOTE• This estim t d 1 ! crin11 Fee: Suppl. InsIg Fee PME Unit Fee: $144.00 PME Permit Fee: $48.00 C,onsiruction Tax. Administrative Fee: IADMIN $45.00 Work Without Permit? Yes (D No $0.00 TOTALS: i Select an Administrative Item Travel Documentation Fee: ITRA VDOC Strom Motion Fee: IBSEISMICR $144.00 Bldg Stds Commission Fee: IBCBSC d Mech. Plan Check0.0 hrs $0.00 1'111t„i'. Plan Chi : ec. Plan Cluck Mech. Permit Fee: /MPERMIT Plumb. Permit Fee: F- c. Perinii Fec i Other Mech. Insp.FO-01 0.0 hrs $48.00 1)ri�e, Plumb IrasP. -L-1 . ­ tiiherElec Insp. Ilech. Insp. kec "hwill. hirp. Fee: h !%asp. Fey NOTE• This estim t d 1 ! crin11 Fee: a e oes not me u e fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These fees are based an d:e nrv1;mim,7r,, - - -- --------- --- FEE ITEMS (Fee Resolulion 11-053 Eff 1.1,73) -•- ... FEE .... w,u u. a QTY/FEE v,u un eSunuae. Contact ru,e De t or aadn't info. MISC ITEMS i'rc,n Check Fee: -Sup/)l. PC Fee PME Plan Check: $0.00 ! crin11 Fee: Suppl. InsIg Fee PME Unit Fee: $144.00 PME Permit Fee: $48.00 C,onsiruction Tax. Administrative Fee: IADMIN $45.00 Work Without Permit? Yes (D No $0.00 01'anced 1,141ami-I 1'tTs. i Select an Administrative Item Travel Documentation Fee: ITRA VDOC Strom Motion Fee: IBSEISMICR $48.00 $0.50 Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $286.50 $0.00 TOTAL FEE: $286.50 Revised: 07/02/2015 LlOWNER -BUILDER DISCLOSURE FORM .. z_ -N COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 - FAX (408) 777-3333 - buildino 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: p perty SITE ADDRESS APN 0 NNER NAME �i C= T f}�1NNER ADDRESS _ /� DESCRIPTION OF WORK: We arerovidin P g 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 (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) understand a frequent practice of unlicensedersons i Builder" buifdin P s to have the property owner obtain an "Owner - g permit that erroneously implies that the property owner is providing his or her ownlabor 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 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 m aware of the limits of my insurance coverage for injuries to workers on my property. -� 2. 1 understand building permits are not required to be signed by property owns rs the construction and are not hiring a licensed Contractor to assume this responsibility. unless they are responsible for 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. I understand Contractors are required b law . numbers on permits and contracts. y to be licensed and bonded in California and to list their license understand if I employ or othenv✓ise engage any persons, other than Califrniatotal value of my construction is at least five hundred dollars ($500), including laborandlicensed materiials, I may beContractors, and the considered an "employer" under state and federal law. I understand if I am considered an "employer" under state and federal law, I federal government, withhold payroll taxes must register with the state and unemployment compensationforeach "employees also understand my failucompensation re to aty bide by these laws n,rance, and r�b subject j me to serious financial risk. may subject 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 {or 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 pert rmed under contract with a licensed general building Contractor. 5 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. 011+1'erBliildeiFo7711,20%O.doc rerued 04114/10 ��. i understand I may obtain more information regarding my obligations as an "employer' from the Int Revenue Service, the United States Small Business Administration, the Califomia Department of Be ma 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, j L� 10.1 am aware of and consent to an Owner -Builder building permit applied my name, anunderstand am the party legally and financially responsible for proposed construction ativity at forlthe site address listed above. that I agree that, as the party legally and financially responsible for this proposed const! by all applicable laws and requirements that govern Owner -Builders as well as employers. action activity, f will abide t,, 12. i agree to notify the issuer of this form immediately of an additions del etions, or changes to any othe information I have provided on this form. Licensed contractors are regulated by laws designed to protect hef 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 co py of the Property owners driver'sform notarization, or other verification acceptable to the city may be required to be presented when'the permit!censeis issued to verify the property owner's signature. Property Owner's Signature: y - Date: 1-171 --------------------------------------------------------------------------------------------------------------------------------------------- (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 Excludina 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 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: OtxaYerBuildeiFa'In_2010.doc i•erised 04/14110