B-2016-1176CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1176
20975 VALLEY GREEN DR APT 228 CUPERTINO, CA 95014-1856 (326 09 041)
KORET FOUNDATION
(OWNER)
OWNER'S NAME: KORET VC I LP
DATE ISSUED: 01/13/2016
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor KORET FOUNDATION (OWN ERI Date
X BLDG —ELECT —PLUMB
X MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
UNIT # 228 - INSTALL (N) WASHER/DRYER HOOK-UPS
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
2. 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
Sq. Ft Floor Area:
Valuation: $500.00
this permit is issued.
APPLICANT CERTIFICATION
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
APN Number:
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
326 09 041
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, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FR ED INSPECTION.
Code, Section 9.18.
Issued by: 1445
Signature Date
IL
Date:
ONVNER-BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
V 2.6*0' I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. 1 have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
�� s. �I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
defined by the Bay Area Air Management District I
shall not employ any person in any manner so as to become subject to the
air contaminants as Quality
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, nd 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner or authorized agent:&,,�
be deemed revoked.
Date: 2P-1-1-160
APPLICANT CERTIFICATION
NSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.1 .
Licensed
Professional
Signat e
V A 1
TOTAL VALUATION:
By my signature below, I certify to each o€the
fbIlawing: I ain
application and die information I have provided is correct. I have rpd theDescription - Of"Work and verify it is arcumlr_ T agree to comply with all
ordinances and state taws relating to building const tion. laalh ercp applicable local
c
Signature of Applicant/Agent: rcsentatives Of Cupertino to enter the above -identified prop c�y for ins9ection purposes
Date:
SUPPLEMENTAL WORMATPq ig'
-'f—'PA'fiSaPR.:201J-d0C revised 06121111
GENERAUPERMIT APPLICA TION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
MEP
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10300 TORRE AVENUE -CUPERTINO. CA 95014-3255
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(408) 777-3228 - FAX (408)-777-3333 orGM
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USE OF 0smarnuPLEx
BUILDn,ta: 0 COM&MRCJAL
Ej MULTIFAMII,Y-
PROiECTINwI 13 M
PRMECrIN 0 YES
ISTiMBLDGAN 0
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URBAN1NTERFACEARZA 13 NO
FLOODZONE ❑I NO
VCHLERHOhIE? 0 No
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TOTAL VALUATION:
By my signature below, I certify to each o€the
fbIlawing: I ain
application and die information I have provided is correct. I have rpd theDescription - Of"Work and verify it is arcumlr_ T agree to comply with all
ordinances and state taws relating to building const tion. laalh ercp applicable local
c
Signature of Applicant/Agent: rcsentatives Of Cupertino to enter the above -identified prop c�y for ins9ection purposes
Date:
SUPPLEMENTAL WORMATPq ig'
-'f—'PA'fiSaPR.:201J-d0C revised 06121111
CITY OF CUPERTINO
W—ft7 FEE ESTIMATOR — BUILDING DIVISION
im,ADDRESS: 20975 VALLEY GREEN DR #228
DATE: 01/13/2016
REVIEWED BY: MELISSA
APN:
BP#:
'EVALUATION: $500
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Multi -Family Dwelling
USE:
Building is
3 Stories 0 Yes G No
PENTAMATION 1 RMAP1
PERMIT TYPE: 911
WORK
UNIT # 228 - INSTALL N WASHER/DRYER HOOK-UPS
SCOPE
Perinit Fee:
Mech. Plan Check 10.0 1 hrs $0.00 111imiL .t'lan t.'heA />ter:. 'l<,r< i'>rec•
Mech. Permit Fee: IMPERMIT
Other Mech. Insp. 0.0 hrs 1 $48.00 0!;ier I;rifTmb Insp,
flha %ib, I>rs'p Fee �?�.... 11:t'i: 1"L'L•'.
VOTE: 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 preliminary information available and are only an estimate. Contact the Dept_tor adan'l tnJo.
FEE ITEMS {Fee Resolution 11-053 E . 7ff d1 Q
FEE
QTY/FEE
MISC ITEMS
.l lon ("heck. Fee:
PME Plan Check:
$0.00
Perinit Fee:
PME Unit Fee:
$144.00
PME Permit Fee:
$48.00
Const'ruclion Tax:
Administrative Fee: IADMIN
$45.00
Work Without Permit? 0 Yes (E) No
$0.00
.rl; to t°£t� .f 1 ri' ttir p F'ee;s:
Travel Documentation Fee: 1TRAVD0C
$48.00
Strong Motion Fee: 1BSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS: "
$286.50
$0.00 ; . " TOTAL FEE: _
$286.50
Revised: .01/01/2016
CUPERTIN4,
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildina0cupertino.ong
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..
gP
OWNER NAME 1 OWNER ADDRESS
!� 1 �.. l , ��
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
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
. I 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 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. I 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.
,�71/ 3. 1 understand as an "Owner -Builder" 1 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.
5' 1/4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5 5. 1 understand if I employ or otherwise 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.
L_/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.
/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.
57 Z/8. I understand as an Owner-Buiider 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.
OwnerBuilderForm 2010.doc revised 04114110
S�9. 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.
5V 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.
;EL11. 1 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.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information Fhave-providedon this form. Licensed contractors are regulated bylaws 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 comp laint...Your only remedy against unlicensed
Contractors maybe in- civil court. itis 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 maybe 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 note
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.)
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 signature. /'
Property Owner's Signature: -,2K Date:
------- -------------------------------------------------------------------------------------------------------------------------------------
(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 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:
OwnerBuilderForm 2010.doc revised 04/14/10