BLD-2021-0739_SignedPermit.pdfBUILDING PERMIT
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 21852 MONTE CT Cupertino
APN: 326 19 081
PERMIT NO: BLD-2021-0739
OWNER'S NAME: GOEL NAVNEET TRUSTEE & ET AL
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 9/23/2021 10:08:47 PM
ISSUED BY:
VALUATION: $175000
JOB DESCRIPTION
(502 SF); (N) 2ND STORY BALCONY (380 SF); 2ND STORY BAY WINDOW ADDITION (22 SF); REMODEL BATHROOMS (386 SF);
CONVERT ATTIC SPACE INTO BEDROOM (274 SF); WHOLE HOUSE REWIRE; INSTALL (N) PROPERTY LINE CLEANOUT; REMOVE (E)
DECK (206 SF); REMOVE SECOND FLOOR BALCONY (120 SF).
ONE STORY ADDITION (308 SF); (N) COVERED PORCHES
REMODEL KITCHEN (325 SF); REMODEL OTHER (950 SF);
BEDROOM #1 FROM FIRST FLOOR AND REPLACE WITH
OWNER -BUILDER DECLARATION
two
wages
with
three
to self -insure
Insurance,
which this
certificate
revoked.
declarations:
as their role compensation, will do the work, and the structure
licensed contractors to construct the project (Sec.
is not intended or offered for sale (Sec. 7044, Business
I hereby
affirm under penatly of perjury one of the following
I, as owner of the property, or my employees with
Code).
& Professions
7044, Business & Professions Code).
I, as owner of the property, am exclusively contracting
affirm under penatiy of perjury one of the following
I have and will maintain a certificate of consent
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the work for
laws of California. If, after making this
with such provisions or this permit shall be deemed
I hereby
declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
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work
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
permit 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
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issued.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
under
the Health
Code,
Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements
the Cupertino Municipal Code, Chapter 9.12 and
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with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Sections 25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety
EPA LEAD -SAFE DISCLOSURE
for this project.
Firm Certification No:
this project.
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for
Certified
CONSTRUCTION LENDING AGENCY
a construction 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
No
Lender's
Name:
APPLICATION CERTIFICATION
the above
of this city
-point
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
source regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I
construction,
harmless the
the applicant
Signature:
have read this application and state that
and hereby authorize representatives
City of Cupertino against liabilities, judgements,
understands and will comply with all non
1,/s:iptst...,G.
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.