BLD-2019-1086BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 22276 HARTMAN DR Cupertino
APN: 326 13 086
PERMIT NO: BLD-2019-1086
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 10/3/2019 12:18:02 PM
ISSUED BY: KDUNBAR
VALUATION: $48000
JOB DESCRIPTION
KITCHEN REMODEL (200 SF); BATH REMODEL (2) (120SF)
OWNER -BUILDER DECLARATION
declarations:
as their role
with licensed
declarations:
for Worker's
as provided
permit is issued,
of exemption,
compensation, will do the work, and the structure
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 following two
I, as owner of the property, or my employees with wages
Code).
le
& Professions
Business & Professions Code).
I, as owner of the property, am exclusively contracting
affirm under penatiy of perjury one of the following two
I have and will maintain a certificate of consent to self -insure
for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,
I certify that in the performance of the work for which this
laws of California. If, after making this certificate
with such provisions or this permit shall be deemed revoked.
I hereby
Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
I shall not employ any person in any manner so as to become subject to the Worker's
I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
issued.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
Chapter 6.95
& Safety
as defined
Sections 25505,
for this project.
of the California Health & Safety Code, Sections 25505. 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements under
the Cupertino Municipal Code, Chapter 9.12 and the Health
with
equipment
Municipal
Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25533, and 25534.
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
lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
affirm
under penalty of perjury that there is a construction
No
�Yes
Lender's
Name:
APPLICATION CERTIFICATION
information
to enter upon
costs, and expenses
source regulations
is correct. I agree to comply with all city and county ordinances and state laws relating to building
the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
which may accrue against said City in consequence of the granting of this permit. Additionally,
per the Cupertino Municipal Code, Section 9.18.
I certify that I have read this application and state that the above
construction, and hereby authorize representatives of this city
harmless the City of Cupertino against liabilities, judgements,
the applicant understands and will comply with all non -point
Signature:
.