BLD-2021-0415CITY OF
BUILDING PERMIT
CITY HALL
10300TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 409-777-3228
CUPERTINO VVyVV ,QJP2TINQ,!Z
BUILDING ADDRE55:i0MR+dre++ I APN:3160201,1 I PERMIT NO: "awl-aea I
I OWNER'S NAME: SAKINo RONAL0 H
DATE ISSUED:3OW200 I ISSHEDRy--nuaao I VAWAitf]wzawo I
JOB DESCRIPTION:
KITCHEN REMODEL (260 SF)
OWNER -BUILDER DECLARATION:
I herebv affirm that I am exempt from the Contractor's License Law for one of the following two reasons:
1] L, as oivrtcr of the property, or my employees with wages as their role compensation, will do the work, and the structure is not
intended or offered for sale , "
B 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business a�
Profession Code).
I hereby affirm under penalty of perjury one of the following three declarations:
13 1 have and will maintain a Certificate of Consent to self -insure for Workers Compensation, as provided for by .1,ectIon 3M a
Mr Codc for the performance of the work for which this permit is issued.
0 1 have and will maintain Workers Compensation hrsurance, as provided for by Section 3700 of the labor Code, for the
performance of the work for which this penvrii is issued.
H 1 certifv that in the performance of the work for which this permit is issued, I shall oat employ any person in any mariner so as to
become subled to the Worker's Compensation laws of California. It after making this certificate of exemption. T become subject to
the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
H 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Satety Code. ,Secn'onh Z 5Q5. 2i5,U-,rod Z534. I
will maintain compliance with the Q11N= lylumcipaLCode,_Chapter 9,12 and the Health & Safety Code, Section 25532(a) should I store or
handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area
Air Quality Management District 1 A ill maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I lealth & Safety Code,
Sections 25505, 255:33, and 26-74.
EPA LEAD -SAFE DISCLOSURE
An EPA Lead -Safe Certified Renovator aiH be responsible for this project.
Certified Firm Name: Firm Certification No:
H No EPA Lead -Safe Certified Firm is required for this pro*L
CONSTRUCTION LENDING AGENCY
1 hereby affirm under penalty of pw1ury that there is a construction lending agency for the performance of the work which this perorit is i sucd
(5ection Si 72, Ca vil Code).
[I Yes HNo
Lender's Name:
r-I J LI!K. Le A!-,lLffl1L9mJg ;I
Lender's Address:
I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state
laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection
purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgements, costs, and expenses which may accrue
> �rting of this permit Additionally, the applicant understands and will comply with all non -point source
against said City in aonsequfrxe of the
regulations p.9the,_ I
� Date � � r✓
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIIED BY SUCH PERMIT IS COMMENCED WITHIN 12 MONTHS AFTER ITS ISSUANCE �
R tF THE WORK AUTHOWED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 12 MONTHS AFTER THE TIME THE WORK tS
COMMENCED.