BLD-2019-1520BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 19147 LOREE AVE Cupertino
APN: 375 07 030
PERMIT NO: BLD-2019-1520
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 12/9/2019 4:24:27 PM
ISSUED BY: JARCHBOLD
VALUATION: $2500
JOB DESCRIPTION
(SEE ALSO B-2019-0259): CONVERT DETACHED GARAGE BACK TO ORIGINAL CONDITION AND RE -INSTALL GARAGE DOOR WITH (N) BEAM AND PORTAL
TO CLEAR CODE CASE
SHEAR WALLS.
OWNER -BUILDER DECLARATION
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
I, as owner of the
Code).
of perjury one of the following
property, or my employees with wages
property, am exclusively contracting
of perjury one of the following
a certificate of consent to self
is issued.
Worker's Compensation Insurance,
performance of the work for which this
California. If, after making this certificate
or this permit shall be deemed
V
& Professions
Business & Professions Code).
I, as owner of the
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
I hereby
two declarations:
-insure 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
revoked.
issued.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
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 under
the Cupertino Municipal Code. Chapter 9.12 and the
with
equipment
Municipal
Health & 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.
V
Certified
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
Yes
affirm
under penalty of perjury that there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state that the
representatives of this city
against liabilities, judgements,
will comply with all non -point
above 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
construction,
harmless the
the applicant
Signature:
have read this application
and hereby authorize
City of Cupertino
understands and
.