BLD-2019-1198_SignedPermit.pdfBUILDING PERMIT
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10235 S DE ANZA BLVD CUPERTINO
APN: 359 10 060
PERMIT NO: BLD-2019-1 198
OWNER'S NAME: SHTEIN PROPERTIES LLC
OWNER'S PHONE: 408-691-3527
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 7/2/2021 8:22:37 AM
ISSUED BY:
VALUATION: $5000
JOB DESCRIPTION
per Alternate Materials and Methods Form. See permit B-2016-2696."
"Remove Fire Sprinkler from Trash Enclosure
OWNER -BUILDER DECLARATION
one of the following three
with wages
contracting with
one of the following two
of consent to self -insure
Insurance,
the work for which this
making this certificate
shall be deemed revoked.
declarations:
as 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 employees
Code).
& Professions
Business & Professions Code).
I, as owner of the property, am exclusively
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 Compensation
I certify that in the performance of
laws of California. If, after
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
permit 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
9.12 and the Health
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have
the
read the hazardous materials
Cupertino Municipal Code, Chapter
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Sections 25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
EPA LEAD -SAFE DISCLOSURE
will be responsible for this project.
Firm Certification No:
required for this project.
An EPA Lead -Safe Certified Renovator
Firm Name:
No EPA Lead -Safe Certified Firm is
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 state that the above
of this city to
judgements, costs,
with 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
construction,
harmless
the applicant
Signature:
•
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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.