BLD-2019-1638BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10136 SANTA CLARA AVE Cupertino
APN: 326 24 015
PERMIT NO: BLD-2019-1638
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 12/23/2019 10:25:58 AM
ISSUED BY: JARCHBOLD
VALUATION: $20000
JOB DESCRIPTION
REMODEL CLOSET INTO A BATHROOM (49 SF).
OWNER -BUILDER DECLARATION
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 of perjury one of the following two
I, as owner of the property, or my employees with wages
Code).
le
& Professions
Business & Professions Code).
I, as owner of the property, am exclusively contracting with
affirm under penatiy of perjury one of the following two
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,
I certify that in the performance of the work for which this
laws of California. If, after making this certificate
with such provisions or this permit shall be deemed revoked.
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
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 Health
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
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
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 state that the above
and hereby authorize representatives of this city
City of Cupertino against liabilities, judgements,
understands and will comply with all non -point
.