BLD-2019-1456BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 1030 NOVEMBER DR Cupertino
APN: 362 15 006
PERMIT NO: BLD-2019-1456
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 11 /27/2019 3:02:32 PM
ISSUED BY: KDUNBAR
VALUATION: $7600
JOB DESCRIPTION
PUMP - (1) INTERIOR UNIT
NEW SPLIT SYSTEM AC HEAT
OWNER -BUILDER DECLARATION
two
wages
with
two
to self -insure
Insurance,
which this
certificate
revoked.
declarations:
as their role compensation, will do the work, and the structure
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 following
or my employees with
am exclusively contracting
of perjury one of the following
a certificate of consent
issued.
Worker's Compensation
of the work for
If, after making this
or this permit shall be deemed
& Professions
Business & Professions Code).
I, as owner of the property,
affirm under penatiy
I have and will maintain
for which this permit is
I have and will maintain
I certify that in the performance
laws of California.
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
the Health
Code,
project.
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 and
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
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this
Certified
v
CONSTRUCTION LENDING AGENCY
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 is
No
V
Lender's
Name:
APPLICATION CERTIFICATION
the above
this city
-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 this
construction, and hereby authorize
harmless the City of Cupertino
the applicant understands
Signature:
application and state that
representatives of
against liabilities, judgements,
and will comply with all non
.