B-2017-1937BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING
OWNER'S NAME: Not provided
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 12/20/2019 9:47:33 AM
ISSUED BY: HALEYM
VALUATION: $300000
JOB DESCRIPTION
REMODEL (192 SF); BATHROOM REMODEL (180 SF); OTHER REMODEL (1315 SF); RE -ROOF- TEAR -OFF- INSTALL
ONE STORY ADDITION (712 SF); GARAGE ADDITION (36 SF); KITCHEN
OSB- COMP SHINGLES (17 SQ).
OWNER -BUILDER DECLARATION
role 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 declarations:
I, as owner of the property, or my employees with wages as their
Code).
& Professions
Business & Professions Code).
V
I, as owner of the property, am exclusively contracting with licensed
affirm under penatiy of perjury one of the following two declarations:
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, as
I certify that in the performance of the work for which this permit
laws of California. If, after making this certificate of
with such provisions or this permit shall be deemed revoked.
I hereby
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
is issued, I shall not employ any person in any manner so as to become subject to the Worker's
exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
issued.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
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 Chapter
the Cupertino Municipal Code, Chapter 9.12 and the Health
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
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 as
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
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
Yes
affirm
under penalty of perjury that there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
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 I have read this application and state that the above
construction, and hereby authorize representatives of this city to enter
harmless the City of Cupertino against liabilities, judgements, costs,
the applicant understands and will comply with all non -point source
Signature:
/
.