BLD-2019-1432BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10074 LIBERTY OAK LN Cupertino
APN: 342 32 046
PERMIT NO: BLD-2019-1432
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 11 /22/2019 8:54:27 AM
ISSUED BY: JARCHBOLD
VALUATION: $3000
JOB DESCRIPTION
FROM GAS METER TO (N) TANK -LESS WATER HEATER
INSTALL 1 1/4" GAS LINE
OWNER -BUILDER DECLARATION
following two
with wages
following two
to self -insure
Insurance,
for which this
this certificate
deemed revoked.
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
I, as owner of the property,
Code).
of perjury one of the
or my employees
am exclusively contracting
of perjury one of the
a certificate of consent
is issued.
Worker's Compensation
performance of the work
California. If, after making
or this permit shall be
& Professions
Business & Professions Code).
I, as owner of the property,
affirm under penatiy
I have and will maintain
for which this permit
I have and will maintain
I certify that in the
laws of
with such provisions
V
I hereby
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
all non -point
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
source regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I have read
construction, and hereby
harmless the City of Cupertino
the applicant understands
Signature:
this application and state
authorize representatives
against liabilities, judgements,
and will comply with
.