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13080215S CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR CONTRACTOR: MORROW-MEADOWS PERMIT NO: 13080215 CORPORATION OWNER'S NAME: KORET FOUNDATION 1050 BING ST DATE ISSUED: 08/28/2013 OWNER'S PHONE: 4082530200 SAN CARLOS, CA 94070 PHONE NO: (650)634-0682 ❑ JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # WASHER/DRYER HOOKUPS Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 (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 Sq. Ft Floor Area: Valuation: $500 performance of the work for which this permit is issued. 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 APN Number: 32609041.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 80OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter -DAYS upon the above mentioned property for inspection purposes. (We) agree to save 180 DA OM LAST CALLED INSPE IO • indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with ail non-point source regulations per the Cupertino Municipal Code, Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection, OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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, Business & Professions Code) , as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino MunicipgfCode, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Secti 25505, 25533, qn4--L5534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agen permit is issued. certify that in the performance of the work for which this permit is issued, I shall 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the upertino Municipal Code, Section Licensed Professional 9.18. Signature a f A\ CUPERTINO CONSTRUCTION PERMIT. APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildingCa)cupertino.org I I MTZW rnWRTRTTr-now n .AnnTTTnm F1 ALTERATION / TT r I RHVTSTON / DEFERRED J V� ORIGINAL PEANaT # PROJECT ADDRESS ATN # -y OWNER NAME, `�y PHONED Y E-MAIL STREET ADDRESS0O J T %I �% CITY, STA ZIP ✓ //� G VART J CONTACT NAME }jy C� /`/ j v (% PHONE E-MAIL WJ �C� IV1 STREET ADDRESS r CITY, STA ZIP P !�� FAX [ ! gG V ®� r OWNER ❑ OWNER-BULLDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBEI�_ © ' LICENSE TYPE G BUS. LIC # 4 COMPANY NAME A /� ® W A / / `� £-MAIL FAX STREET ADDRESS`/ Soo CITY. MCIIn JAi 6AE PHOTIC 56d.--M-19 CLIC ARCHrrECT/ENGINEER NAME LICENSE NUMBER BUS, # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Y l e 41' 1 R" EXISTING USE PROPOSED USE PE #STORffS USE TYPE OCC. SQ.FP. VALUATION (5) EXISTG NEW FLOOR TOTAL AREA AREA [!�#R=DEL NET AREA - BATHROOM KTrCHEN REMODELAREA REMODELAREA AREA PORCH AREA DECK AREA TOTAL DECKRORCH AREA GARAGE AREA DETACH ATTACH # DWELLING UNrM IS A SECOND UNIT ❑YES SECOND STORY El YES BEING ADDED? 13NO ADDITION? []NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF PLANNING APPL # EINO PLANNING APPROVAL LETTER Is THE BLDG AN ❑ YES EICHLER HOME? ❑ NO RECEIVED B TOTAL VALUA By my signature below, l certify to each of the following I am tate property owner or authorized agent to act on the property owner's behalf. I have Ai7d this application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to btli 'ng constnlction. I autho ' e representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: r7 Date: k' A-- f 3 SUPPLEMENTAL INFORMATION REQUIREW PLAN CHECK TYPE ROVTnvG SLIP OVER-TEW-COUNTER Lp� BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for to issuance building existing building(s). Demolition permit is required prior of permit for new building. ❑ EXpREss ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORxs form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to 1:1 MAJOR ❑ 3ANTrARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH. Bldgrlpp 2011.doc revised 06/21/11 V CITY OF CUPERTINO FM_7 FEE ESTIMATOR — BUILDING DIVISION APPLIANCE / EQUIP TYPE FEE ID DATE: REVIEWED BY: 11alADDRESS: APN: BP#: *VALUATION: Iso *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Multi -Family Dwelling USE: Buildina is >3 Stories ® Yes ® No PENTAMATION 1RMAP1 PERMIT TYPE: WORK Other Flee. Insp. Li SCOPE Plumb. hap. Fee: APPLIANCE / EQUIP TYPE FEE ID ._ � • • uE �,e fYi � ,.. 'mak: o .�. QTY UNITS BP FEES Flee. Plan Check Other Appliance/Equip 1BAPPLOT 2 # $140 Other Flee. Insp. Li B:Iech. Insp. Fee: Plumb. hap. Fee: Flec, Ins/). Fee: PME Unit Fee: $140.00 PME Permit Fee: $47.00 C°onslr•uction Tax: Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes (E) No $0.00 TOTALS: A �q^ gb ' . $140.001 g µ .z ;....wir :�."1 .. ..�' e�_�...s' � ._ � • • uE �,e fYi � ,.. 'mak: o .�. Mech. Plan Check 0.0 hrs $0.00 Plumb. Plan Check FT Flee. Plan Check Mech. Permit Fee: IMPERMIT Plumb. Permit herr; Flec. Permit Fee: Other Mech. Insp.0.0 hrs $47.00 Other- Plumb Insp,Li I Other Flee. Insp. Li B:Iech. Insp. Fee: Plumb. hap. Fee: Flec, Ins/). Fee: NOTE: This estimate does not include fees due to other Departments (ie Planning, Public Works, Fire, Sanitary Sewer District, School District. etc ). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/122 FEE QTY/FEE MISC ITEMS Plan Check fere: Suppl. PC 1"ce PME Plan Check: $0.00 Permit Fne: Supp/, Insp I,ee PME Unit Fee: $140.00 PME Permit Fee: $47.00 C°onslr•uction Tax: Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes (E) No $0.00 Advanced Planning Fees: A Travel Documentation Fee: ITRAVDOC $47.00 Strong; Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 xWE y,.t R. HIMM $278.00 $0.00 $278.00 Revised: 07/01/2013 0VIV KfER-B€ til DER D f S C L URE FOR 01 cor,4!��ur�IT -VEL 10300 TORR= ; ,VENU : • CUPER T !N!O; CA 0601 -3253 er1PERT} Yt E (408) 777-3228 • FFA: (4.08) 777-33.33�i�in>;� Dear Prop An applies y Owner(s) n fora building,per�nif has been submiifed in-yodr�ame listing yourself as the_builder of the property_ - -_ s-specine,d ata- -- — ---.---`----_ -_ ----- SITE ADDRESS AM 26 9s' L/ko %rP e -v11233 I 3.2 'JON OF WORK: JAI BPS r .Q fil'1 l oo 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. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKN.OWLED.GNIENT AND VERIFIGATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 1. 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. 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 homeowners 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. S (Al 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: W,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. 115. 1 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_), incfuding labor and materials, I may be considered an "employer' under state and federal law. �6.1 understand If I'am considered an employer" understate and federal law, I must register with the state, and federal government, withhold payroll faxes, proo.vide vrorkers'. compensation disabilify Insurance, and contribute to unemployment compen�afion#oreach'`employee I also uricierstand myfadure to abide by (hese laws may subject me fa `serious -financial . 1 understand. under California Contractors' State License Law, an Owner Builder who builds single-family residential structures cannot legally build them Frith the intent to oder them for sale; unless a/1work is performed by licensed subcontractors and the number of structures does not exceed bur vritnin any -cal -5n da r year or aIf of the work is performed under contract with a licensed general building Contractor. 1 understand as an Owner -Build=er if I sell the prope y .or ,z,�hich :his per, . t s issued, I may be i,eld .furls or { 2ny financial Or personal injuries sustained by any subsea uent owner(S) that result from any latent construction defec,J, the ,,orkmanshipormatcri.els. j O e e tilde form 2010.d, -e iced 04/1!/10` 3, 5V 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 i may contact the California Contractors' State i� icense Board (CSLB) at 1-800-321-CSLB (2752) or www.csfb.ca.gov for more information about licensed contractors. 5(1110. 1 am aware of. and consent to an Owner -Builder building permit applied for in my name, and understand that J am the.party legally and financiailyresponsrpie.for proposed construction activity at the site address listed above. 11.4 agree..that, as the party-iegaily and.fnancialiy responsible for this proposed construction activity, i will abide ___.___byali_applicableAaws_and-mquireinenfs.that-govEtri..-Owner-Buiid$r_s_as_w-eiLas-emplo-y-ers.___—__ _____:_ 12. 1 agree to notify the Issuer of this form immediately of any additions, deletions, or changes to any of the information l.haveprovided on this form Licensed contractors. are regulated. by laws designed to protect the public. if you co�racf wi#�someone who does nof�iave a icense,-ffte--C"ot5�acfois'�tafetfr;e-ns�Bbarcl-Iria�bo-trhabie td� -`--- =:asslst you with any financial loss.you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors maybe in civil courtAt is also important for you to understand that if an unlicensed Contractor or, employee of that individual or firm is injured itilt110 WdMng on your property; you may held liable for damages: if you obtain a permit as Owrier-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 LENDiNO AGENCY (DIFECTIONS. 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.) i 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 responslble.for issuing the permit. Note; A copy of the properly owner's driver's license, form. notarization, or otherverifacation acceptable to the city maybe required to be presenfed whim the permitis issued . . to i�erifv the DrooeW owner's slanature. _ 2 I Prgp'ertyOwner's Signature: . i _2ii�/cl %1t?_.?e Date: �f�/',$�.-/ �. • , T•' j (NOTE. The followlrrg Authorization Form is r&qurred to .be oo�mpleted by the property owrj only when desig'nating an agent of the property owner to apply for a'6onsthrction permit for the Owner -Builder), ,t AUTHORIZATION OF AGENT TO ACTe .ON PRC}PERTI Y OWNER'S BEHALF . f. Pxlud>ng the Notice to Property, Owner, the execution of which 1•understand is my personal i:esporisibility, I hereby :: autiorze the following person{s) to act as myi:agent(s) #o apply for, sign, acid file the docuknenfs necessary to obtain an Owner -Builder Permit for my project. Scope` of.; ohstruction Project (or Description of Work): Prolec#Location or Address:. t ,!t N`s aSr-'A.t Agth>' No k' t . 1 .r... -'s. F S >'q'•s"� tur,':w: u S' z'`� 4 { x _ 3 ' AddressofiAuthonzed Agent t' gent I declare under penalty of p -Wry #hat l am the propertjr p rrner.for the address listed above and I petsonaJly tilJnd out inn _`2 Weld cnd cel ify its_a ;curacy: Nofe: A copy of the propOrtp own6r's dnver's license, form notarizatlr t7, or other verlflcatlon acceptable to the city maybe required to be presented when the pennit is issued to verily the properly owners signature_ Date: Orsrer f:.ralde�l�or:;z �O.IO.�nc � evi;ed 0�/Ir/10 : _