BLD-2021-0009CITY OF
PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10445 STERLING BLVD, Cupertino,
APN:
375 26 015
PERMIT NO: BLD-2021 -0009
CA 95014-3836
OWNER'S NAME: ROWE LYNNE H
OWNER'S PHONE: 408 315 4905
CONTRACTOR: owner builder
CONTRACTOR PHONE:
DATE ISSUED: 2/26/21
' ISSUED BY: HALEYM ' VALUATION: $96,000
JOB DESCRIPTION:
REMODEL KITCHEN (140 SF); REMODEL BATHROOM (40 SF); REMODEL OTHER (10 SF); UPGRADE ELEC
PANEL (125 AMPS); REPLACE WINDOWS (5) AND DOOR (1); INSTALL (4) DUCTLESS HEATING/AC COMBO
UNITS WITH (1) OUTDOOR CONDENSING UNIT; REMOVAL OF FIREPLACE AND INSTALL DOOR AND WINDOW;
BITUMEN ROOFING -CLASS A (15 SQ); REMOVE PATIO COVER (300 SF).
OWNER -BUILDER DECLARATION:
Law for one of the following two
with wages as their role compensation,
& Professions Code).
reasons:
will do the work, and the structure is not
to construct the project (Sec.7044, Business &
as provided for by Section 3700 of the
I hereby affirm that I am exempt from the Contractor's License
I, as owner of the property, or my employees
intended or offered for sale (Sec. 7044, Business
X I, as owner of the property, am exclusively contracting
Profession Code).
I hereby affirm under penalty of perjury one of the following three
-1 I have and will maintain a Certificate of Consent
Labor Code, for the performance of the work
with licensed contractors
declarations:
to self -insure for Worker's Compensation,
for which this permit is issued.
Insurance, as provided for by
is issued.
which this permit is issued, I shall
laws of California. If, after making
Labor Code, l must forthwith comply
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, 1 become subject to
with such provisions or this permit shall be
Li I have and will maintain Worker's Compensation
performance of the work for which this permit
X I certify that in the performance of the work for
become subject to the Worker's Compensation
the Worker's Compensation provisions of the
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I
X I have read the hazardous materials requirements under Chapter
will maintain compliance with the Cupertino Municipal Code,
Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
No:
handle hazardous material. Additionally, should I use equipment or devices which emit hazardous
Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,
Sections 25505, 25533, and 25534.
'7 An EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified Firm Name: Firm Certification
X No EPA Lead -Safe Certified Firm is required for this project.
CQNSTRUCTION LENDING AGENCY
lending agency for the performance of the work which this permit is issued
I hereby affirm under penalty of perjury that there is a construction
(Section 8172, Civil Code).
Li Yes XNo
Lender's Name:
Lender's Address: