BLD-2023-2212_SignedPermit.pdf ITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 19081 BARNHART AVE APN: 375 09 039
PERMIT NO: BLD-2023-2212
OWNER'S NAME: CASIM KAMRAN H AND RUMANA K TRUSTEE
OWNER'S PHONE:916-529-9196
CONTRACTOR: BAY AREA UNDERPINNING INC
CONTRACTOR PHONE:
DATE ISSUED: Nov 17. 2023 ISSUED BY:Abby Ayende VALUATION: 107000
JOB DESCRIPTION: FOUNDATION REPAIR WITH (43) PUSH PIERS AND (18) ADJUSTABLE FLOOR
JACKS
LICENSED CONTRACTOR'S DECLARATION:
NO: EXP DATE: 11/30/2025
867128
7000) of Division 3 of the Business & Professions
CONTRACTOR: BAY AREA
I hereby affirm that I am licensed
Code and that my license is in full
AD30PILE LICENSED
UNDERPINNING INC LICENSED CLASS: BUIEVING DINGAND
DRI
PRESSURE
under the provisions of Chapter 9 (commencing with Section
force and effect.
perjury one of the following three declarations:
maintain a certificate of consent to self -insure for Worker's Compensation,
for the performance of the work for which this permit is issued.
maintain Worker's Compensation Insurance, as provided for by
of the work for which this permit is issued.
in the performance of the work for which this permit is issued, I shall
to the Worker's Compensation laws of California. If, after making
Compensation provisions of the Labor Code, I must forthwith comply
as provided for by Section 3700 of the
I hereby affirm under penalty of
❑ I have and will
Labor Code,
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, I become subject to
with such provisions or this permit shall be
I. I have and will
performance
❑ I certify that
become subject
the Worker's
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
& Safety Code, Sections 25505, 25533, and 25534. I
requirements under Chapter 6.95 of the California Health
M I have read the hazardous materials
will maintain compliance with
handle hazardous material.
Air Quality Management District
Sections 25505, 25533, and 25534.
the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
Additionally, should I use equipment or devices which emit hazardous
I will maintain compliance with the Cupertino Municipal Code,
EPA LEAD -SAFE DISCLOSURE
Renovator will be responsible for this project.
Firm Certification No:
❑ An EPA Lead -Safe Certified
Certified Firm Name:
✓ No EPA Lead -Safe Certified
Firm is required for this project.
CONSTRUCTION LENDING AGENCY
of the work which this permit is issued
I hereby affirm under penalty of
(Section AV7, Civil Code).
perjury that there is a construction lending agency for the performance
Yes El No
Lender's Name:
Lender's Address:
APPLICATION CERTIFICATION
and state that the above information is correct. I agree to comply
and hereby authorize representatives of this city to enter upon
and keep harmless the City of Cupertino against liabilities,
of the granting of this permit. Additionally, the applicant
Municipal Code, Section 9.18.
with all city and county ordinances and state
the above mentioned property for inspection
judgements, costs, and expenses which may
understands and will comply with all non -point
2023
I certify that I have read this application
laws relating to building construction,
purposes. (We) agree to save indemnify
accrue against said City in consequence
source regulations per the Cupertino
Signature 1V Rol Vr SR
Date Nov 17,
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS COMMENCED.