B-2019-0253BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 1 1238 STAUFFER LN Cupertino, CA 95014
OWNER'S NAME: Not provided
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 9/23/2019 3:50:18 PM
ISSUED BY: KDUNBAR
VALUATION: $750000
JOB DESCRIPTION
(4,376 SF); ATTACHED GARAGE (578 SF); COVERED PORCH (1,668)
(N) TWO STORY SINGLE FAMILY HOME
OWNER -BUILDER DECLARATION
one of the following two
with wages as their
contracting with
one of the following two
of consent to self -insure
Compensation Insurance,
of the work for which this
making this certificate
shall be deemed revoked.
declarations:
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 of perjury
I, as owner of the property, or my employees
Professions Code).
Business & Professions Code).
V
I, as owner of the property, am exclusively
affirm under penatiy of perjury
I have and will maintain a certificate
for which this permit is issued.
I have and will maintain Worker's
I certify that in the performance
laws of California. If, after
with such provisions or this permit
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.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
requirements under Chapter
Chapter 9.12 and the Health
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials
the Cupertino Municipal Code,
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
25505, 25533, and 25534.
this project.
Firm Certification No:
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code, Sections
An EPA Lead -Safe Certified Renovator will be responsible for
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
Certified
CONSTRUCTION LENDING AGENCY
that there 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
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state that the above
of this city to
liabilities, judgements, costs,
with all non -point source
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
regulations per the Cupertino Municipal Code, Section 9.18.
I certify that
construction,
harmless
the applicant
Signature:
I
the
have read this application
and hereby authorize representatives
City of Cupertino against
understands and will comply
.