BLD-2021-0964BUILDING 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 264
CUPERTINO
APN: 326 09 041
PERMIT NO: BLD-2021-0964
OWNER'S NAME: KORET VC I LP
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 6/8/2021 3:43:33 PM
ISSUED BY:
VALUATION: $1000
JOB DESCRIPTION
APT #264 - INSTALL WASHER
AND DRYER HOOKUPS
OWNER -BUILDER DECLARATION
I hereby
affirm under penatly of perjury
one of the following three declarations:
I, 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 offered for sale (Sec. 7044, Business
& Professions
Code).
V
I, as owner of the property,
am exclusively contracting with
licensed contractors to construct the project (Sec. 7044. Business & Professions Code).
I hereby
affirm under penatiy of perjury one of the following two
declarations:
I have and will maintain a certificate of consent to self -insure
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for 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.
V
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, I 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 & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
le
with
the 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 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 & Safety Code, Sections 25505, 25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
An EPA Lead -Safe Certified Renovator
will be responsible for this project.
Certified
Firm Name:
Firm Certification No:
V
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 3097, Civil Code).
Yes
V
No
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 Municipal Code, Section 9.18.
Signature:
/41N.
>61\
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.