B-2016-1707 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1707
20975 VALLEY GREEN DR CUPERTINO,CA 95014-1849(326 09 04 1) KORET VC I LP
611 FRONT ST SAN
FRANCISCO,CA 94111
OWNER'S NAME: KORET VC I LP DATE ISSUED:04/06/2016
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OWNER'S PHONE:408-253-0200 PHONE NO:408-493-6445
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#
Contractor KORET VC I LP Date X BLDG _ELECT _ PLUMB
Iheretiy affirm that Lam licensed under the provisions of Chapter (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:
I hereby affirm under penalty of perjury one of the following two declarations: UNIT 210:.WASHER AND DRYER HOOK UP
t. 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.
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 ordinances APN Number: Occupancy Type;
and state laws relating to building construction,and hereby authorize 326 09 041
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 of 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.
�l Signature Date 4/6/2016 Issued by:Alex Valielunga €�
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
1. 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(Sec.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. 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. HAZARDOUS MATERIALS DISCLOSURE
z I 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
�1 d I certify that in the performance of the work for which this pen-nit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
? l/ 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,CAter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 5534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revolted. 'Owner or authorized agent:f)C—,,,
APPLICANT CERTIFICATION Date:4/6/2016
1 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 re ulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Sigrjatu Date 4/6/2016 professional
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DE2VEI W'MENT DEPAR TlUlEhiT
10300 TORRE AVENUE•CUPERTINO,CA 95014-325INC I}1V{SfiOi�T
CUPERTINO (408)7FAX(408)777-3333 buildinaiacuoertino:o
Dear Property Owner(s):
An application for a building permit has been submitted in _ - -
improvements specified at: your name listing Yourself as the builder of the
SITE I1gs Pr°perfY.
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U1=SCRIP'noHOPwORE(:
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We are Providing
you with sOwner-BuilderA incur'adgm ng and lnfarmation Verification Form to make ou
Your responsibilities and possible risk you may incur by having.this passel f issues{in your name as t -- -will not issue a building permit until you have read,initialed your mit issued
in
of amProvision,
y aware of
returned this form to us at aur afficral address indicated. Ana ant of the o heOwner-Builder.. We
you,the property owner,obtain the prior approval of the permitting authority. h cute t is signed,and
wrier cannot execu#e this notice unless
OWNER'S,ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(D' i 1#01VS-Pfease read and initial each statement below to si ni
9 fYYou understand or tie -
r y this information;)
understand a frequent Practice of unlicensed persons is
Buildee'building permit that erroneously implies that the property o neer sve hprov property s Owner r own an r and
personally.1,as an Ownei:Builder,may be held liable and subject to serious financial risk for
an unlicensed person and his or her employees while workingon m yi#arias and material
Provide coverage for those injuries,l am willfully aging as an owner-Builder and am aware a any injuries sustained by
y property. My homeowner's insurance may not
insurance coverage for injuries to workers on my property. f the limits of my
2.I
understand building permits are not required to be signed b Property
the construction and are not hiring a licensed Contractor to-assume h owners unless they are resvansible for
responsibility.
:
3.1 understand as an"Owner-Builder'1 am the responsible
Protect myself from potential financial risk by hiring a licensed C ntractor a
name instead of my own. ndhav ng the permit 11Eed�in his oon the permit I undrstandcher may
.. i understand Contractors are required by taw to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. t understand if I employ or otherwise engage any persons, other than California license
total value of my construction is at least five hundred dollars($500),including labor and materials, l Contractors, and the
considered an"employer under state and federal Jaw..
£. !understand if I am considered an"employer°under state and federal
ister with the state
federal government,withhold payroll taxes, provide workers'compensation disability insurance,a d contribute land
m
unemployment t compeniskion for each"employee:n l also understand my failure to abide by these laws may subject
me to serious financial risk.
5,. /7.!understand under California Contractors'State License Law,an Owner-Builderw
builds
residential structures cannot legally build therm with the intent to offer them for sale, unlesss allwork isiperformed by
licensed subcontractors and the number of structures sloes not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
5 t 8.1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be'meld liable
for
any financial or persona{injuries sustained by any subSequent owner(s)that result from any latent construction
defects iii the workmanship or materials..
Osv'WrBuilderForm_2010 doc revised Q111d1lo
understand l may obtain more information regarding my obligations as an"em
Revenue Service,the United States Small Business Administration,the Califomia Department of B nefit Payments,,
and the California Division of Industrial Accidents. I also understand! may contact th ploys,"from the internal
License Board(CSLB) at'l-$p0-32°l-CSLi3{27 2}or wva r,csllz:ca.gov for more information al Y e
e California Contractors'State
contractors. n about licensed
:IL'f 0. I am aware of and consent to an Owner-Builder building
am the party legally and financially responsible for proposed construction activity at the site address a
permit applied for in my name,and understand that i
ss listed above.
agree that,as the party legally and financially resp®risible for this Proposed
by all applicable laws and requirements that govetra C3wnespon able o well as employers.
P construction activity, l will steads
JJ.Z12 I agree to notify the issuer of this form immediately of any additions, deletions,or changes
information-l-have-provided on this form.Licensed contractors are regulated by_fayrS designed to protectihe.public.to any of the
You contract with someonewho does-not have a license,the Contractors'State -vvs deigned may be t-the.Ip b
assist you with arty financial loss you may sustain as a result of a complaintYour only remedy against unlicensedP tic. if
Contractors maybe in civil court_Itis also important for you-to understand that if an unlicensed Co
employee fthat individual or firm is injured while wor- an our roe g
P ntractor ar
you ob#sin a permit-as Owner-Builder and wish to faire Contractors,you willr :be responsible for vane for damages..If -
those Contractors are properly licensed and the status of their
workers'compensation insurance coverage.
verifying whether ornot-
COl�S7RUCTIQfiI LENE}i�lG AGEi�ICY
kuIRECrTIUNS:Please complete the following construction lending agency information.)
I hereby aifinn that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Maine:
Lender Address:
Before a building permit can be issued,this must be completed and signed by the pr®pe
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's dray owner ws license
form notarization, or other verification acceptable to the city may required to be presented owner the permit IS issued
to ve ; the roe ouvner's si nature
Property Owner's Signature.
Date: �
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IVQTE. The followng Authotrzafian l=orcn is required to 6e ccirnpleted 6y the property ourneronly when designating an
---- ------------------------- -
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ager of the property owner to apply for a construction permit for the Owner-Bu►ider).
AUTI-OP,IZATI NOF AGENT°TO ACT ON PRt)PERTY OWNER'S BEHALF
Excluding the Notice to Property owner,the execution of which I understand is m
I hereby
authorize the following person(s)to act as my agent(s)J'ent(s)to apply for,sign, and fits he documents necessiersonal ary 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.Nota.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 owners
signature.
Property owner's Signature: Date:
0hs+ner.8u':[derForn: 20111.doc revised 04114110