BLD-2020-1215_SignedPermit.pdfBUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 20669 SHELLY DR Cupertino
APN: 359 11 025
PERMIT NO: BLD-2020-1215
OWNER'S NAME: LUU KENNETH K AND PHAM LE-VINH TRUSTEE
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 5/26/2021 5:33:29 PM
ISSUED BY:
VALUATION: $150000
JOB DESCRIPTION
REMODEL OTHER - CONVERT (E) GAR TO ADU (158 SF), CONVERT (E) MAIN HOUSE TO ADU (114 SF); NEW FURNACE IN MAIN HOUSE; NEW ELECTRICAL
NEW ATTACHED ADU (476 SF);
SUB -PANEL, NEW A/C UNIT
OWNER -BUILDER DECLARATION
three declarations:
wages as their
with licensed
two declarations:
to self -insure for
Insurance, as provided
which this permit
certificate of exemption,
revoked.
role compensation, will do the work, and the structure
contractors to construct the project (Sec.
is not intended or offered for sale (Sec. 7044, Business
I hereby
affirm under penatly
I, as owner of the property,
Code).
of perjury one of the following
or my employees with
am exclusively contracting
of perjury one of the following
a certificate of consent
issued.
Worker's Compensation
of the work for
If, after making this
or this permit shall be deemed
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& Professions
7044. Business & Professions Code).
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I, as owner of the property,
affirm under penatiy
I have and will maintain
for which this permit is
I have and will maintain
I certify that in the performance
laws of California.
with such provisions
I hereby
Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
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work
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
is issued, I shall not employ any person in any manner so as to become subject to the Worker's
I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
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issued.
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Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
under Chapter
the Health & Safety
as defined
Code, Sections
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements
the Cupertino Municipal Code, Chapter 9.12 and
le
with
equipment
Municipal
Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety
EPA LEAD -SAFE DISCLOSURE
for this project.
Firm Certification No:
project.
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this
Certified
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CONSTRUCTION LENDING AGENCY
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 that there is
No
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Lender's
Name:
APPLICATION CERTIFICATION
this
-point
the above information
city to enter
costs, and
source regulations
is correct. I agree to comply with all city and county ordinances and state laws relating to building
upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
per the Cupertino Municipal Code, Section 9.18.
I certify that I have read this
construction, and hereby authorize
harmless the City of Cupertino
the applicant understands
Signature:
application and state that
representatives of
against liabilities, judgements,
and will comply with all non
Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period
of 365 days after the time the work is commenced.