BLD-2021-1545BUILDING PERMIT
CUPERTINO
CITY BALI.
10300 Tome Avenue • Cupertino, ('A 95014-3255
PHONE 408-777-3228
WWA1'.('t'PI Xl'INO.ORG
BUILDING ADDRESS: 1 143 IIOLI l'IIFsAD IN Cupertino I
APN: 362 26 019
PERMIT NO: 131,ll-2021-15�45
OWNER'S NAME;
PHONE:
DATE ISSUED 8 11.2021 4:02:07 PM
ISSUED BY: KIM IN13AR
VALUATION: $8338
JOB DESCRIPTION
IN STEMWALLFON'NDAI'ION
VOL1TNTARY IXXTNDATION RI PAIR OF A 4' IIORIZON1'ALCRACK
LICENSED CONTRACTOR DECLARATION
LICENSED NO: 677116
LICENSED CLASS: B GENERAL BUILDING, C-E
9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect.
ExPDATE: 09/30/2021
makingI become subject to the Worker's
this certificate of exemption, 1
CONTRACTOR:
I hereby
I hereby
affirm
affirm
and
and
that
AVALON STRIiCI'URAI. INC
that I am licensed under the provisions of Chapter
under penatly of perjury one of the following
will maintain a certificate of consent to self -insure
will maintain Worker's Compensation Insurance,
in the performance of the work for which this permit
provisions of the Iabor Code, I must forthwith comply
three declarations:
for Worker's Compensation, as provided for by Section 3700 of. the I .ihor ('ode, for the performance of the work for which this permit is issued.
I have
V
I have
as provided for by Section 3700 of the Labor Code, for the perlimnance of the work for which this permit is issued.
is issued, I shall not employ person in an • manner so as to become to the Worker's Compensation laws of California. If, after
any y subjectPe
with such provisions or this permit shall be deemed revoked.
I certify
Compensation
HAZARDOUS MATERIALS DISCLOSURE
6.95 of the California Health & Safety ('ode, Sections 25505, 25533, and 25534. I will maintain compliance with the (Cupertino Municipal ('ode, Chapter 9.12 and the health & Safely Code, Section 25532(a) should I
read the hazardous materials requirements tinder Chapter
hazardous material. Additionally, should I use equipment
25505, 25533, and 25534.
V
I have
store or handle
Code, Sections
or devices which emit hazardous air contaminants as defined by the Ray Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I lealth & Safety
EPA LEAD -SAFE DISCLOSURE
for this project.
,
1 Firm Certification No: a •
. •
a
a
An EPA Lead -Safe Certified Renovator will be responsible
r
Firm Name: a
•
No EPA Lead -Safe Certified Firm is required for this project.
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: a
,
I hereby
affirm
Yes
Name:
under penalty of perjury that there is a construction
No
r ,
a i
Lender's
APPLICATION CERTIFICATION
is correct. I agree to comply with all city and county ordinances
the City of Cupertino against liabilities, judgements, costs, and expenses
9.18.
and state laws relating to building construction, and hereby authorize
which may accrue against said City in consequence of the granting
representatives of this city to enter upon the above mentioned property for
of this permit. Additionally, the applicant understands and will comply with all
I certify that I have
inspection purposes.
non -point source
Signature:
read this application and state that the above information
(We) agree to save indemnify and keep harmless
regulations per the Cupertino \lunicipal Code, Section
I
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 da3 s after the time
the is i Prk is commenced.
Submit