B-2017-1473BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS:
OWNER'S NAME: TRAN KHAI AND MARY ANN HONG G
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 1/16/20203:50:34 PM
ISSUED BY: JARCHBOLD
VALUATION: $769050
JOB DESCRIPTION
ATTACHED GARAGE (429 SF); PORCH (361.6) REV#1 - RELOCATE LAUNDRY ROOM TO THE BASEMENT; ENLARGE 2ND LEVEL
(N) TWO STORY SFD (3369 SF); BASEMENT (1785 SF);
BATHROOM - ISSUED 01/16/2020
OWNER -BUILDER DECLARATION
following two
with wages as
with
following two
to self -insure
Insurance,
which this permit
certificate
revoked.
declarations:
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
I, as owner of the property, or my employees
Code).
& Professions
Business & Professions Code).
I, as owner of the property, am exclusively contracting
affirm under penatiy of perjury one of the
I have and will maintain a certificate of consent
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the work for
laws of California. If, after making this
with such provisions or this permit shall be deemed
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
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 Chapter
and the Health
as
Code, Sections
responsible for
this project.
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
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
Code, Chapter 9.12 and the Health & Safety
An EPA Lead -Safe Certified Renovator will be
Firm Name:
No EPA Lead -Safe Certified Firm is required for
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
that the above
of this city to
costs,
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 I
construction,
harmless the
the applicant
Signature:
have read this application and state
and hereby authorize representatives
City of Cupertino against liabilities, judgements,
understands and will comply with all
.