BLD-2021-1071BUILDING PERMIT
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 7683 SHADOWHILL LN Cupertino
APN: 362 25 017
PERMIT NO: BLD-2021-1071
OWNER'S NAME:
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 8/5/2021 10:09:05 AM
ISSUED BY:
VALUATION: $15000
JOB DESCRIPTION
PART OF BEDROOM TO BECOME A (N) BATHROOM (27 SF)
REMODEL STORAGE ROOM AND
OWNER -BUILDER DECLARATION
one of the following three
or my employees with wages as
am exclusively contracting with
one of the following two
of consent to self -insure
Compensation Insurance,
of the work for which this permit
If, after making this certificate
permit 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,
Code).
& Professions
Business & Professions Code).
V
I, as owner of the property,
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.
with such provisions or this
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
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have
the
read the hazardous materials requirements under Chapter
Cupertino Municipal Code, Chapter 9.12 and the Health
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 as
Code, Chapter 9.12 and the Health & Safety Code, Sections
EPA LEAD -SAFE DISCLOSURE
Renovator will be responsible for this project.
Firm Certification No:
Firm is required for this project.
An EPA Lead -Safe Certified
Firm Name:
No EPA Lead -Safe Certified
Certified
V
CONSTRUCTION LENDING AGENCY
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 there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state that the above
representatives of this city to
liabilities, judgements, costs,
comply with all non -point source
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.