BLD-2019-1504BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 1323 FLOWER CT Cupertino
APN: 366 18 041
PERMIT NO: BLD-2019-1504
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 2/1 1 /2020 3:13:15 PM
ISSUED BY: HALEYM
VALUATION: $0
JOB DESCRIPTION
AND (2) BATHROOMS (995 SF); UPGRADE SEWER LINE AS NEEDED. SEE PERMIT B-2019-0783 FOR DRAWINGS
CONSTRUCT (N) ADU WITH (2) BEDROOMS
OWNER -BUILDER DECLARATION
of the following two
with wages
contracting
of the following two
of consent to self -insure
Insurance,
work for which this
making this certificate
shall be deemed revoked.
declarations:
as their role compensation, will do the work, and the structure
with 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
I, as owner of the property, or my employees
Code).
le
& Professions
Business & Professions Code).
I, as owner of the property, am exclusively
affirm under penatiy of perjury one
I have and will maintain a certificate
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the
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.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
requirements
9.12 and the
under
Health
Code,
project.
Chapter 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, Chapter
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
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this
Certified
v
CONSTRUCTION LENDING AGENCY
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 that
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and
state that
of this
judgements,
with all non -point
the above
city
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 have read this application
construction, and hereby authorize representatives
harmless the City of Cupertino against liabilities,
the applicant understands and will comply
Signature:
.