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10090216 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21230 HOMESTEAD RD BLDG 1 CONTRACTOR:VALLEY GREEN PERMIT NO: 10090216 ASSOCIATES ' NER'S NAME: VALLEY GREEN ASSOCIATES _31 E DANA ST DATE ISSUED:09/27/2010 OWNER'S PHONE: 4082045367 VIOUNTAIN VIEW,CA 94041 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB License Class Lic.# MECH r RESIDENTIAL[- COMMERCIAL Contractor Date JOB DESCRIPTION:APT 1-8-INSTALL 16 NEW BEDROOM WINDOWS I hereby affirm that I am licensed under the provisions of Chapter 9 BEDROOM (commencing with Section 7000)of Division 3 of the Business&Professions WINDOWS TO MEET 2007 CVC Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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. I have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$7500 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: permit is issued. APPLICANT CERTIFICATION APN Number:32605085.1 Occupancy Type: 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 and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Date: !r– 2'"7 6 Issued by,�7 �-' ,uro Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed cont t to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following t declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants s defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain c li nce with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health of Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I nth ed ent: Z J become subject to the Worker's Compensation provisions of the Labor Code,I u> Date: forthwith comply with such provisions or this permit shall be deemed revoked.!! CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above info ion is I hereby affirm that there is a construction lending agency for the performance of work's (Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relatin;; for which this permit is issued to building construction,and hereby authorize representatives of this city to enter Lender's Name the above mentioned property for inspection purposes.(We)agree to save Lender's Address ..inify and keep harmless the Ci f Cupertino against liabilities,judgments, costs,and expenses which may rue against said City in consequence of the granting of this permit.Add* ' nally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point s gulat a Cupertino Municipal Code,Section 9.18. y I understand my plans shall be used as public records. Signa Date // �� Licensed Professional `2-J CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$7,500 -� xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition / Repair PRIMARY 101 ! PENTAMATION 1GENRES USE: SFD or Duplex 11 i 0,0i'l 1�1 L;'l PERMIT TYPE: WORK SCOPE 14-rpt_ Pt2rf 1 NOTE: Thesefees are based on the preliminary in ormatiot!available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS ('Fee Resolutioft 09-051 Elf. 7:'1%'10) FEE QTY/FEE MISC ITEMS Plan Check Fee: 60.00 16 # Window/Sliding Glass Door Suppl. PC Fee: 0 Reg. 0 OT 0.51hrs 60.00 $506.00 1 WINREP Replacement PME Plan Check: $0.00 Permit Fee: 50.00 Suppl. Insp.Feer Reg. 0 OT 0.0 hrs :30.00 PME Unit Fee: 60.00 PME Permit Fee: 50.00 C.`r�tzslt•tx�ticltz 7�r.�� Acoustical Fee: 0 Yes (E) No 60.00 Work Without Permit? 0 Yes E) No 60.00 E) Planning Fee: 60.00 Select a Non-Residential Building or Structure Ci-�tti��1 I':)c�errlrr��arut�nil 1�'<�E�,: Strong Motion Fee: 1BSEISMICR $0.75 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 __71 SUBTOTALS: 61.75 $506.00 TOTALFEE.T $507.75 Revised: 9/14/2010 CITY O:? CUPERTINO 3 ITEMS OF 21 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . . 3.2605085 .1 DATE ISSUED. . . . . . . : 0 )/27/2010 RECEIPT #. . . . . . . . . : B,3000011566 REFERENCE ID # . . . : 1)090216 SITE ADDRESS . . . . . : 21230 HOMESTEAD RD BLDG 1 SUBDIVISION . . . . . . CITY CJPERTINO IMPACT AREA . . . . . . OWNER VkLLEY GREEN ASSOCIATES ADDRESS . . . . . . . . . . : 131 E DANA ST CITY/STATE/ZIP . . . : MDUNTAIN VIEW, CA 94041 RECEIVED FROM . . . . : BRIAN AVERY CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY VkLLEY GREEN ASSOCIATES ADDRESS . . . . . . . . . . : 131 E DANA ST CITY/STATE/ZIP . . . : MDUNTAIN VIEW, CA 94041 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 7, 500 . 00 1 .00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 7, 500. 00 0 .80 0. 00 0 .80 0 . 00 1WINREP EACH 8 16 . 00 506 . 00 0.00 506 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 507 .80 0 .00 507 . 80 0 .00 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JUl3 ADDRESS' I t ` � y7-j PERMIT# vZ� OWN ER'S NAME: a. r ��- c,� �so PHONE# - y._3� _ GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: S D i Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY '.NSPECT WILL BE SCHEDULED UNTIL THF. GENERAL CONTRACTOR AND ALL SUBC ORS HAV OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. ' — - 1 am not using any subcontractors: Date Sig nature Please check applicable subcontractors and complete the following information: j/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal ElShEeetockEEE Owner/Contractor Signature Date OWNER-BUILDER DISCLI3SURE FORM COMMUNITY DEVELOPMENT DEPARTP4ENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, GA 95014-3255 (408)777-3228- FAX(408)777-3333• bLL ildingacupertino.ora CUPERTINO 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 / i1PN BP# OWNER AME =OWNERAD[�RESS a „�A �� cr,,w1 �, ,�C Ce DESCRIPTION OF WORK: We are providing you with an Owner-Builder Acknowledgm,mt 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, init aled 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 pe-miffing authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIzuilder" NS:Please read and initial each statement belc w 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 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 insur ce coverage for injuries to workers on my property. . I understand building permits are not required lo be signed by property owners unless they are responsible for construction and are not hiring a licensed Contractpr to assume this responsibility. understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may otect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4-understand Contractors are required by law t)be licensed and bonded in California and to list their license f�ers on permits and contracts. t � understand if I employ or otherwise engage a ny persons, other than California licensed Contractors, and the aI value of m construction is at least five hundred dollars($500), including labor and materials, I may be Y Yrde 'dered an"employee' under state and federal law. 6. I understand if I am considered an "employer" under state and federal law, I must register with the state and algovernment,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 serious financial risk. I understand under California Contractors' StE to License Law, an Owner-Builder who builds single-family 7.r idential 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 structureE does not exceed four within any calendar year, or all of the work 78. 1 rt med under contract with a licensed general tuilding Contractor. s issued, I may e held understand asn an juries sustained nediider f by all the property for ny s b equent ownerch this(s)that result tlfrom any latent construction onle for any financial or persona � defects in the workmanship or materials. OwnerBuilderForm_1010.doc revised 04/14/10 ; understand I may obtain more information regarding my obligations as an"employer"from the Internal eve4n.uTe 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 ww,w.cslb.ca.gov for more information about licensed contractors. . I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I the parry legally and financially responsible for proposed construction activity at the site address listed above. agree that, as the party legally and financially responsible for this proposed construction activity, I will abide allapplicable laws and requirements that govern Ow ier-Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the ormation 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. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while worki-ig 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 if 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 iss ,this form must be completed and signed by the property owner and returned to the agency responsib or issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verificaf' acce a fo-the-c►t'�nay be required to be presented when the permit is issued to verifythe property owner's si atu ) Date-. --4-7- Property ate: zProperty Owner's Signature: --"� --------------------------------------------------------------------------------------------------------------------------------------------- (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,vhich 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 document necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: 1 2 20 / " f� Name of Authorized Agent: m,, (-,6, Tel No BUY` ZC' Address of Authorized Agent: /7 06-11 -D"4 A." �(� 7 L'4 C- Lev 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. te:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may b quired to be presented when the permit is issued to verify the property owner's signature. Date: �> 7 Property Owner's Signature: OwnerBuilderForni_2010.doc revised 04/14/10 CITY OF CUPERTINO CITY OF CUPEIZT]NO GENERAL BUILDING PERMIT APPLICATION FORM APN Date: ,�. G Building Address: Mailing Address (if different from building address):pp r ._ Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work only) Yes ❑ No G�i.f y es, provide letter from HOA Owner's Name: Phone#: Contractor: Phone: Fax: '- ,_D > 3 Contractor License#: Cupertino Business License#: Contact: Phone: 4,6" 9u I." Fax: ��,I��c:� � � �? �'"? o Residential Commercial Job Description: Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 11 1-A, 1-B ❑ II/III/V-A ❑ IIJIII B, IV-HT, V-B Valuation: —0& Square Footage: Project Size: Express Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicabl!, include in plan set& the sheet index. oints Achieved: - - For help, contact Build it Green at www.builditiM!en.or Revised 07/14/09