BLD-2020-0403BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 19340 CALLE DE BARCELONA Cupertino
APN: 375 05 019
PERMIT NO: BLD-2020-0403
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 3/2/2020 2:09:43 PM
ISSUED BY: KDUNBAR
VALUATION: $1000
JOB DESCRIPTION
NEW PROPERTY LINE CLEAN OUT
REPLACE SEWER LINE; INSTALL
OWNER -BUILDER DECLARATION
one of the following two
with wages as their
contracting with
one of the following two
of consent to self -insure
Compensation Insurance,
of the work for which this
making this certificate
shall be deemed revoked.
declarations:
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
I, as owner of the property,
Professions Code).
of perjury
or my employees
am exclusively
of perjury
a certificate
is issued.
Worker's
If, after
or this permit
Business & Professions Code).
V
I, as owner of the property,
affirm under penatiy
I have and will maintain
for which this permit
I have and will maintain
I certify that in the performance
laws of California.
with such provisions
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 under Chapter
Chapter 9.12 and the Health
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,
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
25505, 25533, and 25534.
this project.
Firm Certification No:
or devices which emit hazardous air contaminants
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
that 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
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state that the above
of this city to
liabilities, judgements, costs,
with all non -point source
.