BLD-2021-0341BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
BUILDING ADDRESS: 10514 MADRONE CT Cupertino APN: 342 60023
OWNER'S NAME:
CONTRACTOR: OWEN SIGNATURE HOMES INC, 445 SO SAN ANTONIO STE 201 LOS ALTOS
DATE ISSUED 3/4/2021 3:02:18 PM _ I ISSUED BY: haleym
JOB DESCRiPTION
KITCHEN REMODEL - (300 SF)
LICENSED CONTRACTOR DECLARATION
CONTRACTOR: 01', EN LICENSED CLASS:
' RE - =4.1E5 irc
LICENSED NO: 309180
B GENERAL BUILDING CO
PERMIT NO: BLD-2021-0341
OWNER'S PHONE:
CONTRACTOR PHONE:
VALUATION: $20000
EXP DATE:
[2I31I2O22
I hereby affirm that 1 am licensed under the provisions of Chapte r t (commencing wittl, islan 7000) of Division 3 of the lxuslrNrss & ProfeuionE
Code and that my license is in fuN force and effect.
I hereby affirm under penatly of perjury one of the following three declarations:
I have and will ma'ntaln a certificate of consent to se t- nsure for Worker's Compensation, as provided for ny Section 3700 of the Labor_code.
for the performance of the work for which this permit is issued.
eX44have and will ma "-tain Workers Compensation Insurance, as provided for by Section 3700 of the Labor Code, for tree performance of the
work for which this perm" is issued.
I cer•it. that's 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 taws of Carfornia. If, after making this certificate of exemption, I become subject to the Worker's
Compensation provisions of the Laoor Code I must forthwith comply ;r i1h such provisions or ?ri:s permit shall be deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
ave read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code. Sections 25505. 25533, and
25534, I WI malnta'n compliance with the . i pter 9.12 and the Health & Safety Code, Sector, 25532(a) should I store
or handle hazardous material. Additionally. should f use equipment or devices which emit hazardous air contaminants as defined by the Bay Area
Air Qua9ty Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 a'-d the Hea & Safety Code,
Sections 25505.25533, and 25534. _
EPA LEAD -SAFE_ DISCLOSURE
= EPA Lead -Safe Certified Renova--)r be responsible for tnls project.
Certified = •-. Name:
o EPA Lead -Safe Certified Firm required for this c ec
CONSTRUCTION LENDING AGENCY
Firrn Cep'' - n No:
I hereby affirm under penalty of perjury that there is a construction ;ending agency for the performance of the work wnlch this permit Is issued
(Section 3097, Civil Code).
Yes
Lender's Name: i
APPLICATION CERTIFICATION
Lender s Address'
I certify that I have read this application and state that the above Information is correct, 1 agree to comply with a city and county ordinances
and state laws resat ng to L., ding construction. and hereby authorize representatives of this city to ter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the City of C _ _ - agains• sties, judgements, costs, and expenses
which may accrue against said City in consequence of the granting of this perm" Additionally: the op- " - . understands and comply with a"
t source regulations per the Qjpertino Municipal ±kode. Section 9,18,
Signature:
Every permit issued shotl become nvolld unless the work on the site authorized by such permit is commenced within 365 days after his issuance, or it the work authorized on Hie site by such permit
is suspended or abandoned for a period of 345 days after the lime the work is commenced.