B-2017-0233 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0233
20990 VALLEY GREEN DR APT 604 CUPERTINO,CA 95014-1832(326 09 053) OWNER BUILDER
OWNER'S NAME: KORET VC I LP DATE ISSUED:02/08/2017
OWNER'S PHONE:408-253-0200 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER BUILDER 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 604-INSTALL WASHER AND DRYER HOOK UPS
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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
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 09 053
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.
Additionally,the applicant understands and will comply with all non-point 'WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 02/08/2017 Issued by:Kim Dunbar
Date:02/08/2017
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. 1,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)
' z.J
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:02/08/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
2. 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
California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. 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
shall not employ any person in any manner so as to become subject to the 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 25505,25533,a 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall 4
/
be deemed revoked. Owner or authorized agen • '
APPLICANT CERTIFICATION Date:02/08/2017
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 r ulations per the Cupertino Municipal ARCHITECT'S_DECLARAT1ON
I understand my plans shall be used as public records.
Code,Section 9 8.
Licensed
Signatu 6701-> 6`11"21.---1) Date 02/08/2017 Professional
GENERAL PERMIT APPLICATION MEP
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. .. COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
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By my sigrn.tre.below,I certify to each of the.followba: I die xoperty osmer trt authorized astmt to act=the proomiy ownes betta/f. I have rnd d..viS •
aDDHC:stiOtt md tbe:;-2.far=don I have provided is coma I have read t1 Desoto:don of Work and verify it is accurate. I age e to comply with all applimble local
crdireices ergi state laws relating toair...g co-••= n-;. •:,b oa. I autbor;Ter presemutives of Cuperdzo to eat.=lac above-idteafilied Foperq for ii2sp ,-..,-.doo.puzpses.
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SUPPLEMENZALINTORMATION
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lieRritriscdpp 2011 aloe revised 06/21111
_ _
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
4.51-15,4 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO- (408)777-3228•FAX(408)777-3333 buildinatacuoartino.oro
_
Dear Property Owner(s):
An application for a
ecifiedbuilding permit has been submitted in your name listing yourself as the builder of the property
improvements spat
SITE ADDRkSk, -
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BP*
orRU-AtrisEsy _ _ 0WN_R
- • - E•e' I -
_DESCRIPTION OF WORK:" fei *OA' el/31
• •
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We are providing you with an Owner-Builder AcknoMedgment and Information Verification Form to makeyou aware of
your responsibilaies 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 sinned 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'$ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verily this information.)
1/i. 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. 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.
-
)j ._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.
3.I understand as an'Owner-Builder I 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.
-) V 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5 ti 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.
6.1 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.
1/7. 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 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.
OwnerBuilderForm_2010.doc revised 04/14110
5(1 9.1 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 1 may contact the California Contractors'State
License Board(CSLB) at 1-800-321-CSLB(2752)or wwvv.csib.ca.gov for more information about licensed
contractors. _
1//1 10. I 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.
5- Li 1. I 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.
- 1 L/12. I 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 may-be in civil court. If is also important for you-to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working 6n 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 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 verify the property owner's siogi&re,. ,.
Property Owner's Signature: --PI-2--72/4) 64.2-7.7,--4--)
Before a
2--023--/ .?--(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 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 properly 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.
Date:
Property Owner's Signature:
Owner13zaderForrn 2010.doc revised 04/I 4/10
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CJJPER%]O�O SANITARY DISTRICT ° �
2VDO3O�venaCmekBlvd#1VV. Cupertino, CA 95014
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Tel(408)253'7071 Fax (408)253-5173 �*�"— �� C"r ~`.~m
SANITARYDISTRICT I�� ������� ETTER
Cupertino Sanitaty District has adopted Resolution No1263.
Building Permit Request
� (Over-the-Counter)
--1 Single Family Project ' AvyWu|U-Fannih Project 1 1 Commercial Project
Project Address: 7499 96 4del
(`,re em 0r, 1- 4 ) o /Y� l
'
Permit Number: 4-13—
24 e)/ 3. ;
Scope of Work: z6(.1,04A.0.-V/71-1-/-P C he,94 be-- iip-s
Owner/Applicant AO rel fy, (.v/00 1, 0
I/ade
Date: ~� �7 ��� xPrap�radBv� o�~
�
' ' - City Authorized Representative
I, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements
will be met and all required fees will be .aid prior to the appr val of finalinspection for proposed project.
�'�4eta:2�w-�-� � -''�Zgnatur. �°* ' '' '
`' Ovvner/AuthohzedAgent
[�[]PEF�T1�J{} SANITARY DISTRICT OFFICE USE ONLY
~ Pny')nopeot|onRequin»d [-� Final }nopenUonRequired
- Date Scheduled:
(---
Date: q -5-~ \ • Conditional Approval By: '/7��
. \
Authorize nntoUvn
Cupertino Sanitary District
District will notify o . oroftherequi,edfoavvith\n5dayoafterPre'|nnpaoUonhanbonnnump\atodondoc
City of Cupertino.
Inspection Fee Paid Date Paid:
Inspection Fees:
| I $250/unit Single Family Residential already connected, but new cleanout is required
I-1 $150/unit-Single Family Residential already connected with existing cleanout in working order
| I $350 Minimum-Commercial and Retail Actual Amount: .
I I $200/each-Disconnect and/or abandon lateral service
Connection Permit Fees: .
| I $350/unit-Single Family Residential connecting to existing lateral
Li $650/unit-Single Family Residential connecting with new lateral
I | $1OO/unit-Multi, Hotel, Living Units, etc. Actual Amount:
I I $500/connection -Commercial and Retail Actual Amount:
Connection Use Fees(See Attached Calculation Sheet):
I I Area and Frontage Fees Amount:
ri Residential Excess Fees over 3.5 unit/acre Amount:
| I Commercial and Retail Connection Fees Amount:
I I Commercial and Retail Change in Use Fees Amount:
Date: . Final Approval By:
Authorized Representative
Cupertino Sanitary District