BLD-2021-1036BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 277
CUPERTINO
APN: 326 09 041
PERMIT NO: BLD-2021-1036
OWNER'S NAME: KORET VC I LP
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 6/8/2021 3:35:32 PM
ISSUED BY:
VALUATION: $0
JOB DESCRIPTION
HOOKUPS
APT #277 - INSTALL WASHER AND DRYER
OWNER -BUILDER DECLARATION
one of the following three
employees with wages as
exclusively contracting with
one of the following two
of consent to self -insure
Compensation Insurance,
of the work for which this permit
after making this certificate
shall be deemed revoked.
declarations:
their role compensation, will do the work, and the structure
licensed contractors to construct the project (Sec. 7044.
is not intended or offered for sale (Sec. 7044, Business
I hereby
affirm under penatly of perjury
I, as owner of the property, or my
Code).
& Professions
Business & Professions Code).
V
I, as owner of the property, am
affirm under penatiy of perjury
I have and will maintain a certificate
for which this permit is issued.
I have and will maintain Worker's
I certify that in the performance
laws of California. If,
with such provisions or this permit
I hereby
declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
as provided 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
of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
issued.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
requirements under Chapter
Chapter 9.12 and the Health
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials
the Cupertino Municipal Code,
le
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
defined 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 as
Code, Chapter 9.12 and the Health & Safety Code, Sections
EPA LEAD -SAFE DISCLOSURE
will be responsible for this project.
Firm Certification No:
is required for this project.
An EPA Lead -Safe Certified Renovator
Firm Name:
No EPA Lead -Safe Certified Firm
Certified
V
CONSTRUCTION LENDING AGENCY
that there is 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
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and
liabilities,
with
state that the above
of this city to
judgements, costs,
all non -point source
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I have read this application
construction, and hereby authorize representatives
harmless the City of Cupertino against
the applicant understands and will comply
Signature:
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.