10080074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20990 VALLEY GREEN DR APT 639 CONTRACTOR:KORET FOUNDATION PERMIT NO: 10080074
OWNER'S NAME: KORET FOUNDATION 20875 VALLEY GREEN DR DATE ISSUED:08/10/2010
4ER'S PHONE: 4082530200 CUPE 3TINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB r
License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL F
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 BOD DESCRIPTION: INSTALL WASHER&DRYER UNITS INSIDE COMM'L APTS
(commencing with Section 7000)of Division 3 of the Business&Professions
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 Sq.Ft Floor Area: Valuation:$100
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN'.Vumber:32609053.639 Occupancy Type:
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 and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, `'VITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the ]80 D YS FROM CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
0.
9.18. IssuEd by � `/
/ d Date:
Signature Date
LV OWNER-BUILDER DECLARATION RE-ROOFS:
All rc ofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of instal,ed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspe.tion.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signs ture of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I hai a read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the Calif ornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. 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 Safe y Code,Section 25532(a)should I store or handle hazardous material.
Add tionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this cont iminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I qwi er or authoriz , O
become subject to the Worker's Compensation provisions of the Labor Code,I must �l n�'�t{�`�_`",�" Date:l
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I her eby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Len ier's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Len ler's Address
mnify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I un lerstand my plans shall be used as public records.
9.18.
OO
Licr used Professional
Signature A,jA A► w �l Date V
�ITY OF CL;PERTINO
: a AATOR—B1UILDING DIVISION
- DATE: REVIEWED BY,
;:P#t•
*VALUATION: i
PLAN CHECK TYPE: Alteration/Addition
Eluildina is
[APPLICATION>3 Stories ® Yes No E: w�pp.
FLR AREA PC FEES PC FEE ID BP F k S
s.f.
0 $0.00
_ CC $0.00 c�
. =0
wt
Elec.Plan Check u
:umb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: 1PPERMIT Elec•per
'.rfer Plumb Insp. 0.0 hrs $42.00 Other Elec.Insp.
in oxmati� 'oo ..i le and are onlyan estimate. Contact the D0.0
c
,�,
10) FEE QTY/FEE MISC ITEMS.,
$0.00 1 # Electrical
._M $O.UO $42.00=Plumbing
Recep/SorsI $0.()0 �� #$0.00 $42.00Piping. Are, _
_.:yrs $0.1)0
$0.00
$126.00
NO $0.30
No $0.00
_ $0.00 Select a Non-Residential
Building c.;
_—�-- Travel Documen
$050
Bsc $1.00 $42.00 1TRAVDOC
$127.50 $126.00 FEEe�I
.e_
CITY OF CLrPERTINO
7 ITEMS OF 7 PERMIT F.ECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32609053 .639
DATE ISSUED. . . . . . . : 08/10/2010
RECEIPT #. . . . . . . . . : BS000011150
REFERENCE ID # 10080074
SITE ADDRESS 20990 VALLEY GREEN DR APT 639
SUBDIVISION . . . . . .
CITY CUPERPINO
IMPACT AREA . . . . . .
OWNER KORET FOUNDATION
ADDRESS . . . . . . . . . . : 20875 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPER`CINO, CA 95014
RECEIVED FROM . . . . : VILLAGES AT CUPERTI
CONTRACTOR LIC; # *OWNER*
COMPANY KORET FOUNDATION
ADDRESS 20875 VALLEY GREEN DR
CITY/STATE/ZIP . . . : CUPER-INO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- ---------- ----- ----- ______
----------
1BCBSC VALUATION 100. 00 1 .00 0. 00 1. 00 0 . 00
1BREMRECEP NO. OUTLETS 1. 00 42 . 00 0.00 42. 00 0. 00
1EPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42. 00 0. 00
1MPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 . 00
1PPERMITFE FLAT RATE 1. 00 42 . 00 0. 00 42. 00 0 . 00
1PREPPIPE FLAT RATE 1. 00 42 . 00 0. 00 42. 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0.00 42. 00 0. 00
253 . 00 0.00 253 . 00 0 . 00
TOTAL PERMIT :
---------- ----------
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------------- --------------------
CHECK 253 . 00 #19862
---------------
TOTAL RECEIPT 253 . 00
Li
CITY OF CUJPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLIC.A.TION FORM
APN# DatP
--
Building Address: �. �; -2-)
Zo o
Mailing Address (if different from building addr ss):
C G✓
Owner's Te. Phone#:
�L eK H o ,9- Z5 -0 Zoo
HOA: (Exterior work only) Yes ❑ No f
If yes, provide letter from HOA
Contractor: Phone:
' 6 6 Fax:
Contractor License#:
Cupertino Business License#:
Phone: Lf aj�- �? .S.z"746 yj
Contact: � ` �� 'u er
Fax: LJaL q73jo ZS'
Residential Commercial ❑
Job Description:
Co ci f cc A ,,-4 11d: r � S
Building Permit Info: —/
Mech
BldgElect � Plumb Lid'
Type of Construction(Usage Class): Occupancy Type:
AI
1-A, 1-B F-1II/III/V-A ❑ II/III B, IV-HT, V-B
f
Valuation: Square Footage:
/ 0a
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 applicable, include in plan set& the sheet index.
Points Achieved: .
For help, contact Build it Green at www.builditlZreen.or
Revised 02/05/09
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
C U P E RT I N O (408)777-3228• FAX(408)777-3333• , - -,
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 API BP#
OWNER NAME OWNER ADDRESS
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment 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. /,n 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
(DIRECTIO S:Please read and initial each statement below to signify you understand or verify this information.)
I understand a frequent practice of unlicensed persc ns is to have the property owner obtain an "Owner-
Builder'building permit that erroneously implies that the prc perty owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and :ubject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while worki ig 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.
'`�2. 1 understand building permits are not required to be Signed by property owners unless t
the construction and are not hiring a licensed Contractor to;assume this responsibility.
they are responsible for
J\f J . I understand as an "Owner-Builder" I am the respon::ible party of record on the permit. I understand that I ma
protect myself from potential financial risk by hiring a licensE d Contractor and having the permit filed in his or her y
name instead of my own.
_X-� . I understand Contractors are required by law to be li(;ensed and bonded in California and to list
��n�umbbers on permits and contracts. their license
Yom`"' 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
zunderstand
ed an "employer" under state and federal law.
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
W7.
rious financial risk.
understand under California Contractors'State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the inteni to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does n:)t exceed four within any calendar year, or all of the work
is pe rmed under contract with a licensed general building Contractor.
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.
0*nerBui1derFonn_2010.doc revised 04/14/10
'yy9. I 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 undo rstand I may contact the California Contractors'State
License Board(CSLB)at 1-800-321-CSLB (2752)or www.cs b.ca.gov for more information about licensed
contractors.
0. 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.
11. I agree that,as the party legally and financially resp msible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-E.uilders as well as employers.
\�2. 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 resul:of a complaint.Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you 'o understand that if an unlicensed Contractor or
employee of that individual or firm is injured while 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 thoir workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lend ng 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 ma�be required to be presented when the permit is issued
to verify the pLoeerty owner's signature.
Z�ECUT5_
Property Owner's Signature: Date:
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be coripleted by the property owner only when designating an
agent of the property owner to apply for a construction permit f)r the Owner-Builder).
AUTHORIZATION OF AGENT TO ACTON 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 apple for, sign, and filelthe 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
presented when the permit is issued to verify the property owner's
verification acceptable to the city maybe required to be
signature.
Property Owner's Signature: Date:
OwnerBuilderForm_2010.doc revised 04/14/10