BLD-2019-1261BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 19895 FIG TREE CT CUPERTINO
APN: 316 30 077
PERMIT NO: BLD-2019-1261
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 10/28/2019 11:54:01 AM
ISSUED BY: JARCHBOLD
VALUATION: $22363
JOB DESCRIPTION
(1) SLIDING DOOR
REPLACE (13) WINDOWS LIKE FOR LIKE; REPLACE
OWNER -BUILDER DECLARATION
following
with wages
contracting
following
to self -insure
Insurance,
for which this
this certificate
deemed revoked.
two declarations:
as their role compensation, will do the work, and the structure
with licensed contractors to construct the project (Sec. 7044,
is not intended or offered for sale (Sec. 7044. Business
I hereby
affirm under penatly of perjury one of the
I, as owner of the property, or my employees
Code).
& Professions
Business & Professions Code).
I, as owner of the property, am exclusively
affirm under penatiy of perjury one of the
I have and will maintain a certificate of consent
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the work
laws of California. If, after making
with such provisions or this permit shall be
V
I hereby
two declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's
of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
issued.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
under
and the Health
Chapter 6.95 of the California Health & Safety Code, Sections 25505. 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements
the Cupertino Municipal Code, Chapter 9.12
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Sections 25505, 25533, and 25534.
for this project.
Firm Certification No:
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
Certified
v
CONSTRUCTION LENDING AGENCY
is a construction lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
Yes
affirm
under penalty of perjury that there
No
V
Lender's
Name:
APPLICATION CERTIFICATION
that the above
of this city
judgements,
all non -point
.