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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 .