BLD-2021-0916BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10671 JOHNSON AVE Cupertino
APN: 375 31 049
PERMIT NO: BLD-2021-0916
OWNER'S NAME:
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 5/21/2021 4:53:25 PM
ISSUED BY:
VALUATION: $1400
JOB DESCRIPTION
INSTALL TEMPORARY POWER POLE - (100 AMP)
OWNER -BUILDER DECLARATION
of the following three
with wages as
contracting with
of the following two
consent to self -insure
Insurance,
work for which this permit
this certificate
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 one
I, as owner of the property, or my employees
Code).
& Professions
Business & Professions Code).
V
I, as owner of the property, am exclusively
affirm under penatiy of perjury one
I have and will maintain a certificate of
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the
laws of California. If, after making
with such provisions or this permit shall
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
9.12 and
under Chapter
the Health
as
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
V
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
Code, Chapter 9.12 and the Health & Safety
EPA LEAD -SAFE DISCLOSURE
will be responsible for this project.
Firm Certification No:
for this project.
An EPA Lead -Safe Certified Renovator
Firm Name:
No EPA Lead -Safe Certified Firm is required
Certified
V
CONSTRUCTION LENDING AGENCY
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 that
No
V
Lender's
Name:
APPLICATION CERTIFICATION
state
judgements,
with all
that the above
of this city to
costs,
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
construction,
harmless
the applicant
Signature:
I have read this application and
and hereby authorize representatives
the City of Cupertino against liabilities,
understands and will comply
,
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.