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BLD-2021-1486CITY OF BUILDING PERMIT lug Tc;f1nu AvENJE • C;UPE-R'T040 CA 950i,4-325+ ONE 40(7+r•'d2P j Al'M. 532 ©RANGE BLflSSt�M DR GU rtino CA 1 95014-5225 366 11 OW OWNER'S NAME: owxfR s PHONE $ »t+<nTtiNc 9LD? 2021-1486 �vneRne.ttJR: owner bv#rlar CONTRACT_OK ►NON1x. DATE ISSUED.8/212i ISSUED BY: ha"__..-VAWATFOW $100 JOB DESCRIPTION: REPLACE BUILD tNG SEWER LiNE AND 1N TRLL PRPERT LINE CLEANOUT AND FQ UNUATION CLF,6NQVT t 6 QWNER-BUILDER DECLARATION: 1 hereby affirm that 1 am exempt from the Contractors License Law for one of the following two reasons: i a owner of the praperty or m% empl. tees with wage as their role compensation, will do the work, and the structure is not intended to offered for sate (ma`s ,.?,•.t ru :�+ea• & • „r�.+ n. 4.at.) 4 i, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.i¢44, Business & Profession Cadet'. q I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Dyt, f71 .srj} (�A _ igiti for the performance of the work for which this permit is rued, t I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subtect to the Workers Compensation laws of California If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, F must forthwith comply with such provisions or this permit shall be deemed revoked. ,� 1 have read the hazardous materials requiremenLc under Chapter 695 of the C ihfornF, F i�th�r ,�if�1g C�c� S�t�n.�i{(,5�;�5t,;�n�j�5�;.t• I wttl maintain compliance with the C upgrt �t ni y� 1 the �_hapte _ G,l4 and the I3ealth &Safety Code, Section 25532(ai should F atone or handle hazardous material. azardous air contaminants Additionally, should I use equipment or devices which emit has defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25,,533, and 25539. An EPA Lead -Safe Certified Renovator will be responsible for this Protect. Certified Firm Name: Firm Certification No: I hereby affirm under penalty of perjury that there is a construtlion lending agency for the performance of the work which this permit is issued (Section 81?2, Civil Codel. Yes �No Lender's Name: Lender's Address: I certify that I have read this apptication 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 against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino "Unictnil Ccsde, ti "itt n�; . Signature tip•^ •% Date 202 , PERMIT ISSUED SHAH BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 12 MONTHS AFTER ITS ISSUANCE, OR IF THE WORK RIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR A6ANDONED FOR A PERIOD OF 12 MONTHS AFTER THE TIME THE WORK IS COMMENCED.