BLD-2019-0857CITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO. CA 95014,3255
PHONE 408-777-3228
CUPERTINO WWWCUPERTINO.ORG
BUILDING ADDRESS:
APN:
PERMIT NO: BLD-2019-0857
10221 STERLING BLVD, Cupertino, CA 95014-3827
375 25 001
OWNER'S NAME:
OWNER'S PHONE:
CONTRACTOR:
CONTRACTOR PHONE:
DATE ISSUED: 3/30 20 ISSUED BY: hale m I VALUATION: 10000
JOB DESCRIPTION: (N) REAR ADDITION (448 SF); REMOVE/ REBUILD ROOF STRUCTURE AND RAISE PLATE HEIGHT/
REMODEL OTHER (876 SF); REMODEL KITCHEN (127 SF); REMODEL BATHROOMS (89 SF TOTAL); (N) FRONT PORCH (19
SF); UPGRADE MAIN ELECTRICAL PANEL (200 AMPS); REPLACE WATER HEATER SAME LOCATION: REPLACE FURNACE
AND A/C UNIT; FULLY SPRINKLER BUILDING
OWNER -BUILDER DECLARATION,
I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons:
L as owner of the property, or my employees with wages as their role compensation, will do the work, and the structure is not
intended or offend for sale fS7(1 W. Busints fi Professions Code).
L as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec,7044, Business &
Profession Code).
I hereby affirm under penalty 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 tie
Labor Codefor 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.
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,1 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 a: Safety Code. Sections 25505. 2-K%3 and 25531. I
will maintain compliance with the Cu}k rtino Mtmicilhil Code. Chapter 4.12 and the Health $ Safety Code, Section 2,5532(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 dr Safety Code,
Sections 25505, 25533, and 25534.
An EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified Firm Name: Firm Certification No:
✓ 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 8172, Civil Code).
- Yes o
Lender's Name:
Lender's Address:
APPLICATION CERTIFICATION
I 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 enter upon the above mentioned property for inspection
purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgements, costs, and expenses which may accrue
against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source
regulations per the Cupertino lhuudpal Code. StxLion 9.18,
-il�
Signature C l� Maw 2AM
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 12 MONTHS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 12 MONTHS AFTER THE TIME THE WORK IS
COMMENCED.