BLD-2025-1258_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: 18844 HUNTER WAY ApN: 375 35 064
PERMIT NO: BLD-2025-1258
OWNER'S NAME: HA CHAI TRUSTEE & ET AL
OWNER'S PHONE: 408-398-9192
CONTRACTOR: OWNER -BUILDER
CONTRACTOR PHONE:
DATE ISSUED: May 22, 2025 ISSUED BY: AbbyAyende VALUATION: 500
JOB DESCRIPTION: INSTALL TEMPORARY POWER POLE (100 AMP)
OWNER -BUILDER DECLARATION:
the Contractor's License Law for one of the following two
property, or my employees with wages as their role compensation,
for sale (Sec. 7044, Business & Professions Code).
reasons:
will do the work, and the structure is not
to construct the project (Sec.7044, Business &
as provided for by Section 3700 of the
I hereby affirm that I
am exempt from
as owner of the
or offered
as owner of the
Code).
penalty of perjury
and will
Code, for
I,
intended
RII,
property, am exclusively contracting with licensed contractors
one of the following three declarations:
maintain a Certificate of Consent to self -insure for Worker's Compensation,
the performance of the work for which this permit is issued.
maintain Worker's Compensation Insurance, as provided for by
the work for which this permit is issued.
the performance of the work for which this permit is issued, I shall
to the Worker's Compensation laws of California. If, after making
provisions of the Labor Code, 1 must forthwith comply
Profession
I hereby affirm under
I have
Labor
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 have
and will
of
that in
subject
Worker's Compensation
revoked.
performance
M I certify
become
the
deemed
HAZARDOUS MATERIALS DISCLOSURE
& Safety Code, Sections 25505, 25533, and 25534. I
materials
with
material. Additionally,
District
and 25534.
requirements under Chapter 6.95 of the California Health
M I have read the hazardous
will maintain compliance
handle hazardous
Air Quality Management
Sections 25505, 25533,
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,
should I use equipment or devices which emit hazardous
I will maintain compliance with the Cupertino Municipal Code,
EPA LEAD -SAFE DISCLOSURE
will be responsible for this project.
Firm Certification No:
QAn EPA Lead -Safe
Certified Firm Name:
k.7)No EPA Lead -Safe
Certified Renovator
Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
of the work which this permit is issued
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance
(Section 8172, Civil Code).
0 Yes I 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,
the granting of this permit. Additionally, the applicant understands
Code, Section 9.18.
with all city and county ordinances and state
the above mentioned property for inspection
judgements, costs, and expenses which may accrue
and will comply with all non -point source
2025
I certify that I have read this application
laws relating to building construction,
purposes. (We) agree to save indemnify
against said City in consequence of
regulations per the Cupertino Municipalr
Signature YrgaG 4GG71v4L
Date May 22,
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 12 MONTHS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 12 MONTHS AFTER THE TIME THE WORK IS
COMMENCED.