B-2016-1175 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1175
20990 VALLEY GREEN DR APT 654 CUPERTINO,CA 95014-1837(326 09 053) 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 (OWNERI 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#654-INSTALL(N)WASHER/DRYER HOOK-UPS
I hereby affirm under penalty of perjury one of the following two declarations:
r. 1 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
this permit is issued. Sq.Ft Floor Area: Valuation:$500.00
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 09 053
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 OFIT 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 F A ALLED INSPECTION.
Code,Section 9.18.
Issu
Signature Date Date: r l y l
OWNER-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:
t/2.41' 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. I 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
,V L13.f 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
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the 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,and 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 agents4& .-
be deemed revoked. Date:4V l ter–f �� d
APPLICANT CERTIFICATION CONSTRUCTION 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 18.
Licensed
Signat Date l' ; �l-/d Professional
GENERAL PERMIT APPLICA i[ON
COMMUNI i Y DEVELOPMENT DEPART MEN i•BUILDING DIVISION M E up
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
n (408)777-3228• FAX(4-08)777-3333- buildlnO0CLJDerIno.Orq
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A/lP-4 !'scflDp 2011.doc reinsed 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20990 VALLEY GREEN DR#654 DATE: 01/13/2016 REVIEWED BY: MELISSA
APN: BP#: *VALUATION: $500
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY Multi-Family Dwelling Buildina is PENTAMATION 1 RMAP1
USE: >3 Stories 0 Yes (DNo PERMIT TYPE: A
WORK UNIT# 654 - INSTALL N WASHER/DRYER HOOK-UPS
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 1BAPPLOT 2 # $144
TOTALS: $144.00
Mech.Plan Check 0.0 hrs $0.00 :hw;ib,,PIa t t:710,:,-k >fec. .l lar,Claecl
Fech.PemitFee: 1MERIT ' .n . 1<nwii!�,ee.MFlee-
Other
Mech.Insp. 0.0 hrs $48.00 od-le;I;'r.Olb 11?c
,�;)P{f%A IJ?sp, �`�r.'e �.c,...ID7:,ti.I''£'L'.
NOTE.This estimate does not include fees due to other Deparonents(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These,fees are based on the prelindnar information available and.are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS (Fee Resolution 11-053 E . 711/13) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
,l'erniit Fee:
St�ppl_h7q)Fee
PME Unit Fee: $144.00
PME Permit Fee: $48.00
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes (D No $0.00
Travel Documentation Fee: ITRAVDOC $48.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg St ds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $286.50 $0.00 TOTAL FEE: 1 $286.501
Revised: 01/01/2016
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINQ (408)777-3228- FAX(408)777-3333•buildinaacupertino.orp _-
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-. g
OWNER NAME OWNER ADDRESS-
- •��.-
DESCRIPTION OF WORK: •' " ,eA-'
We are providing you with an Owner-BuilderAcknovwledgment 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.)
1. 1 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. 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 am aware of the limits of my
insurance coverage for injuries to workers on my property.
U 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.
5J3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that l 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.
5V 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.
J 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.
15-6"
5- 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.
j / 7. 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.
5 JL8. 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.
OwnerBuilderForm 2010.doc revised 04/14/10
^ r
D9. 1 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.
ZZ- 1 0. 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.
� -11. 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.
3„�_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 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 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 veri6l the property owner's si nature.
Property Owner's Signature Date:
------- -------------------------------------------------------------------------------------------------------------------------------------
(NOTE . The following Authorization Fonn 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: 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:
OwnerBuilderForm 2010.doc revised 04114/10
SMOKE f CARBON MONOXIDE ALARMS
,. OWNER CERTIFICATE OF COMPLIANCE �
COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION 7t; 7.7ij
(CU PERTINO 10300 TORRE AVENUE o CUPERTINO, CA 95014-3255
(408)777-3228 4 FAX(408) 777-3333- building as cupertino.orq
r�---- - ��ade:
PR-kilT CANNOT BE PINALEID AND C01APILETED UNT11,THIS CERTIFICATE
TO Mr.
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s)
On every level of a dwelling unit including basements X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-buming appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s)may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above-referenced property,I hereby certify that the alarm(s).referenced above has/have been
installed in.accordance with the rmanufacturer's instructions and in compliance with the California Building
and Cali forma Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
6 have read anal a ree,to comply with the,bar mm, and conditions.of this statement
` VA' � OA Sf i
. ............................................Date
Conira'&o Mame:
Si�"iati�e..............- .LiDate` k
Smoke and COform.dbc revised-03/1'8/1:4°
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
c �
COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION
Cl1PER,T,ir➢CD 10300 TORRE AVENUE e CUPERTINO,CA 95014-3255
(408)777-3228 o FAX(408)777-3333- building6a)-cupertino.ona
Owner Name C) 1Z��` U d 4f 1, 1/- 71j,/ Permit No
Address C °1 e-� = e.) S<
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections l l 1.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
\No Go to Question 2.
2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property or its
plumbing,installation of water-conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 110 1.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
KNo Go to Question 3. /
(f5
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 110 1.1 through 1101.8/do n apply. Skip the rest of the form and sign bottom of form.
❑ No Go to Question 4.��G� G
4. Is your real property built and available for use or occupanc on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
❑ Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 ap,y. Check one of the three following statements and sign
bottom of form.. �i�IY4�
5. Please check ONE of the following:
FMy property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building.On or before January 1,2017,all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a.multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019,all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building(regardless of whether property undergoes alterations or
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1,2014,specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
I,as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1101.8,the current California Plumbing Code and California Green Building Standards Code, and manufacturer's
installation requirements,and that the water-conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Si nature.F Dat
Upon completing and signing this Certificate,please return it tot e Building Division in order to final your building permit.
SB407 2015.doc revised 08/26/15