BLD-2020-15521/7/2021
CITY OF CUPERTINO BUILDING PERMIT
BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
W W W.CUPERTiNO.ORG
BUILDING ADDRESS: 10494 FLORA VISTA AVE Cupertino APN: 326 28 082
PERMIT NO: BLD-2020-1552
OWNER'S NAME:
OWNER'S PHONE: Not Provided
CONTRACTOR: PRIME BUILDERS, 44075 FREMONT BLVD FREMON7
CONTRACTOR PHONE:
DATE ISSUED 1/7/2021 3:11.07 PM ISSUED BY: Sean Hatch
VALUATION- $77000
JOB DESCRIPTION
FIRST STORY ADDITION (273 5F), REMODEL OTHER (72 SF)
LICENSED CONTRACTOR DECLARATION
CONTRACTOR: PRIME BUILDERS LICENSED CLASS: LICENSED NO- ICO2799 EXP DATE:
B GENERAL BUILDING COIF 04/30/2021
1 hereby affirm that I am licensed under the provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business JL Professions Code and that my license is in full force
and effect,
I hereby affirm under penally of perjury one of the following three declaraltons:
1 have and well maintain a certificate of consent to self -insure for Worker's Compensation, as provided far by Section 3700 of the Labor Code, forthe performance of the work for
which this permit is issued.
I ave 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.
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 became subject to the Worker's Compensation
ws o arifomia-1f, 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
have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safe y Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with
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Cupertino Municipal 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 emif 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.
EPA LEAD -SAFE DISCLOSURE
An EPA Lead -Safe Cerlified Renovator will berespon-b-le-o"thls project.
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Certified Firm Nome: i Find Certification No::
L--------------------------------- J
EPA Lead -Safe CerFIffled Firm is required for this project.
CONSTRUCTION LENDING AGENCY
thereby penalty of perjury that there is a construction lending agency for the performance of the work which this permff is issued (Section 3097, Civil Code),
R11under
YesLender's
E ( Lender's Address: ;
L---------------------------------J
APPLICATION CEWTIFICATION
I certify that I have read this application and state that the above inforrnation 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 Municipal Code. Section 9. f 8-
Signature:
Esery permit issued shut become rnvofid artless the work on the sit authorized by such permit A commenced wifhin 365 days after us Issuance, or ft the work ouftrodwd on the site by such permil is suspended or abandoned far n "ilod or 355
days after the time the wok is commences
$Llbmit
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