B-2019-1126 PERMITi OWNER'S NAME: Not provided r,
.- i �CONTRACTOR PHONE:
CONTRACTOR:I
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i DATE ISSUED 7/22/2019 3:39:34 PM (; ISSUED BY: KDUNBAR s VALUATION: $30000
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BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
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BUILDING ADDRESS: 10972 WILKINSON AVE CUPERTINO, 1
CA 95014-4700 CUPERTINO APN: 356 13 054 PERMIT NO: B-2019-1 126
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JOB DESCRIPTION
REMODEL KITCHEN - (196 SF)
LICENSED CONTRACTOR DECLARATION
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OWNER'S PHONE: Not Provided
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CONTRACTOR:I
LICENSED CLASS:
LICENSED NO:
EXP DATE:
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I hereby affirm that I am licensed under the provisions of Chaoter 9 (commencina with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
force and effect.
I hereby affirm under penatly of perjury one of the following three declarations:
I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
v
I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
comply with such provisions or this permit shall be deemed revoked.
,HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 2,5505. 25533. and 25534. I will maintain compliance
with the Cupertino Municioal Code. Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534.
An EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified Firm Name:
v
No EPA Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Firm Certification No:
IYesV No
Lender's Name:
Lender's Address:
APPLICATION CERTIFICATION
certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to _entter up.onjhe-ctbove mentioned property for inspection purposes. (We) agree to save indemnify and keep
harmless the City of Cupertino aggfliabilities, judgements, cos sf and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
withSn-