BLD-2021-1954CITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 7588 ORANGE BLOSSOM DR ApN: 366 11 059
PERMIT NO: BLD-2021-1954
OWNER'S NAME:
CONTRACTOR: OWNER -BUILDER
CONTRACTOR PHONE:
DATE ISSUED: 2021-10-13 ISSUED BY: Jasmine Archbold VALUATION: 500
JOB DESCRIPTION: INSTALL AN AUTOMATIC SEISMIC GAS SHUTT-OFF VALVE AFTER THE GAS METER
OWNER -BUILDER DECLARATION:
reasons:
will do the work, and the structure is not
to construct the project (Sec.7044, Business &
as provided for by Section 3700 of the
I hereby affirm that I am exempt from the Contractor's License Law for one of the following two
I, as owner of the property, or my employees with wages as their role compensation,
intended or offered for sale (Sec. 7044, Business & Professions Code).
RII, as owner of the am exclusively contracting with licensed contractors
property,
Profession Code).
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,
Labor Code, for the performance of the work for which this permit is issued.
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, I become subject to
with such provisions or this permit shall be
I have and will maintain Worker's Compensation Insurance, as provided for by
performance of the work for which this permit is issued.
M I certify that in the performance of the work for which this permit is issued, I shall
become subject to the Worker's Compensation laws of California. If, after making
the Worker's Compensation provisions of the Labor Code, 1 must forthwith comply
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
& Safety Code, Sections 25505, 25533, and 25534. I
M I have read the hazardous materials requirements under Chapter 6.95 of the California Health
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
handle hazardous material. Additionally, should I use equipment or devices which emit hazardous
Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,
Sections 25505, 25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
No:
QAn EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified Firm Name: Firm Certification
k.7)No EPA Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
of the work which this permit is issued
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance
(Section 8172, Civil Code).
0 Yes I No
Lender's Name: Lender's Address:
APPLICATION CERTIFICATION
with all city and county ordinances and state
the above mentioned property for inspection
judgements, costs, and expenses which may accrue
and will comply with all non -point source
I certify that I have read this application and state that the above information is correct. I agree to comply
laws relating to building construction, and hereby authorize representatives of this city to enter upon
purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities,
against said City in consequence of the granting of this permit. Additionally, the applicant understands
regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date Oct 13, 2021
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 12 MONTHS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 12 MONTHS AFTER THE TIME THE WORK IS
COMMENCED.