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B-2016-1706 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1706 20875 VALLEY GREEN DR CUPERTINO,CA 95014-1799(326 09 064) KORET VC I LP 611 FRONT ST SAN FRANCISCO,CA 94111 OWNER'S NAME: KORET VC I LP DATE ISSUED:04/06/2016 OWNER'S PHONE:408-253-0200 PHONE NO:408-253-0200 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lie.# Contractor KORET VC I LP Date X BLDG _ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: UNIT 25-WASHER AND DRYER HOOK UP 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 this permit is issued. Sq.Ft Floor Area: Valuation:$500.00 APPLICANT CERTIFICATION 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 326 09 064 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 expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting all this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with.all non-point source regulations per the Cupertino Municipal Code,Section 9.18• 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 4/4/6/2016 Issued by Abby Ayende � Date:04/06/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is i. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection, sale(Sec.7044,Business&Professions Code) I,as owner of the property am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(See.7044,Business&Professions Code). Date:4/6/2016 - I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. 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. HAZARDOUS MATERIALS DISCLOSURE 2. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the a I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25553,3 as d 25534. Labor Code,I must forthwith comply with such provisions or this permit shall �� be deemed revoked. Owner or authorizedti"� APPLICANT CERTIFICATION Date:4 2 1 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097;Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities; judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION t Code,Section 9.18, 1 understand my plans shall be used as public records. Date 4/6/2016 Licensed Professional GENERAL PERMIT APPLICATION CONPAUNITY DEVELDPIAEN 1 DLP„R-1 h4ENT-BUILDING DIVISION MEF 10300 T ORRE AVENUE-CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228-FAX(448)`t77-3333•buildinaC CuDerinoarc PLUIS _ misu `ED— nima ED , lZC?J zy1r_R-cc _ owA�23ti WE S _ l y _ -� 5sn= lOP'.' A Aca1wj eY ijne Owe I ' ? r`. o2a © ovn��3u - az;, �c�,t i:3 cot.: cro� Cohai;�croRtC�,� D Lt t.7cc, ❑ a ,o= p 3UQ T Z- and -Sh'"A '(O' Ins (�Asa A stirrr; �;�3s _ Cr=f_z _ , _ � FAQ . { Cam,sumi zl2 TPRONS is_(iF I� .ps'uar. ?.3'�?Ti-P7�.!'R,..Y ?R03_Cl'Lkei.' L?�.7• E3 YM 13`ES -3u ©CDLk, is —'-s i�1`'-s?'�J�C_=� �'?3F� �d V. E?.Y4 (�h'D � i2A07�7Ak': �j*:F7 � =z 7F-1ZC?Jn0N OF wo?Z1 - app>>C"euo2 and iffice e-Sf0.atioz I have P-rmiQCd is Correct 1-have read the De=iptWoff Avork c'"aa Yrity ii S accura:e...I z e#to comply S . r:'nem . ' 9. .•• 1A i a a�a�"Ca fTe�OCcl G C.1.r,C..S a;2C!a_a cSi p: �c..^.�.i0 '"'..L*2�C u� '0zt., 2Lc^Da•�S �3..5..,'lizuSreS t�fCl!D��1 i0 e�..i i3C.c�lat•:34".�'�F«Q 'oaet a i:e .•-- a5,-e ®"`}'TOF.. JVC`i103aL's'iiose5. fis`cp.nate ofnip iC�^-e..i/.:r..',:ti: Date: SLIPPLENMNITlAZTrO-R7,?A.TTQ?\ j�: '-"- � C£ 5 R ONE- - ��.r?i�u��D�?t111.�ac retris��06.n.�fll OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 2 10300 TORREAVENUE-CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•buildinQ(¢�- �,a�r.,,. ,__ Dear Property Owner(s): An application for a buildingylisting Permit has been submitted in our name listin improvements specified'at; g yourself as the builder of the property � _ � • APIC ` y4�Jpiff/may jj c(�•meq '- VYY tlHfY��yr,.�, -�`r.6u _'_ \\ 9 IY '13p* s]2 cog - DESCR1P710N OF WORK: eii We are providing you with an Owner Builder Acknowledgment and Information Verification Form to make You aware Your responsibilities and possible risk you may incur by having this permit issuer! in your name as the Owner-Builder.of will not issue a building permit until you have read,initialed your understanding of each provision" We returned this form to us a#our official address indicated. An agent of the Owner cannot execute this i - you, the property owner,obtain the prior approval of the permitting authority. ,signed-,unand Halle,,unless OWNER'S AMCKI WLEpGMENT AND VERIFICATION OF INFORMATIO (u1rtt�;i iU S:Tease read and in1f1a1 each statement below to sin1 g fy you understand or verify this information.) 2 V1. I understand a frequent practice of unlicensed persons is to have the property Builder"building permit that erroneously implies that the roe p pedy owner obtain an"Owner- Builder"building as an Owner-Builder, may be held liable and subject to serious rfinanal risk fooviding his or r any injr own ures sustainted 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 1.isurance coverage for Injuries to workers on my property. 15 2.1 understand building permits are not required to be signed by property the construction and are not hiring a licensed Contractor to-assume this ss uowners nless they are responsible for 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. :' 4.l understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 3, 5.I 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. . ( 6.I understand if I am considered an"employer"under state and federal law,[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.. 57.1 understand under California Contractors'State License Law,an Owner-Builder who builds residential structures cannot legally build them with the intent to offer them for sale, unless all work islperformed 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. 119 1 )—V S.l 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. OvnerBuilderForm 2010.doc revised 04114110 9.1 understand I may obtain more information regarding my obligations as an'employee"from the Internal Revenue Service,the United States Small Business Administration,the California Department of Benefit Payments, and the California Division of industrialAccidents. I also understand l 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. 10. 1 am aware of and consent to an Owner-Builder building am the party legally and financially responsible for proposed construction it applied cti activity atthe s toaddress listed above. me, and understand that i 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 govem Owner-Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes.to an of the information-i-have-provided on this form.Licensed contractors are regulated by_laws designed to protect tha public. if. you contract with 7someone who does not have a license,the Contractors'State License Board may be unable to assist you with oily 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 while working on dourproperty, .. - 9 y you may be held liable far 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 oftheirworkers'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 pertmR 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 accepfab/e to the city may be required to be presented when the permit is issued - to verffy the property owner's si nature Property Owner's Signature: = Date: ------ --- ------------------------------------ -------• ---------------------------------- ------------------------------------------------ {NOTE: The following Authorization Form is required to be completed by rhe 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 l 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 l personally filled out the above information and certify its accuracy.Note.A copy of the property owner's drivers 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: QwnerBuitderForm_2010.doc revised 04114110