BLD-2020-0618CITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO wWW.CUPERTINO.ORG
BUILDING ADDRESS: 22136 DEAN CT, CUPERTINO CA APN: 357 09 030
PERMIT NO: BLD-2020-0618
OWNER'S NAME:
OWNER'S PHONE:
CONTRACTOR: SAM'S CARPET & FURNITURE INC
CONTRACTOR PHONE: 4082382384
DATE ISSUED: 05/20/2020 [ISSUED BY: JASMINE ARCHBOLD 1 VALUATION: $9250
JOB DESCRIPTION:
REMODEL BATHROOM (88 Sf)
LICENSED CONTRACTOR'S DECLARATION:
EXP DATE: 03/31/2021
7000) of Division 3 of the Business & Professions
CONTRACTOR: SAM'S CARPET & FURNITURE INC LICENSED CLASS: B LICENSED NO: 1002543
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section
Code and that my license is in full force and effect.
as provided for by Section 3700 of the
I hereby affirm under penalty of perjury one of the following two declarations:
.i 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
shall not employ any person in any manner so as to
this certificate of exemption, I become subject
comply with such provisions or this permit shall
/
i7 I have and will maintain Worker's Compensation Insurance, as provided for by
performance of the work for which this permit is issued.
L I certify that in the performance of the work for which this permit is issued, I
become subject to the Worker's Compensation laws of California. If, after making
to the Worker's Compensation provisions of the Labor Code, I must forthwith
be deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
& Safety Code, Sections 25505, 25533, and 25534. I
Se 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:
U An EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified Firm Name: Firm Certification
/
St No EPA Lead -Safe Certified Firm is required for this project.
of the work which this permit is issued
CONSTRUCTION LENDING AGENCY
I hereby affirm under pe ty of perjury that there is a construction lending agency for the performance
(Section 3097, Civil Cod .
Ll Yes L o
Lender's Name:
Lender's Address:
APPLICATION CERTIFICATION
comply with all city and county ordinances and
upon the above mentioned property for
liabilities, judgements, costs, and expenses which
understands and will comply with all non -
) — It() ,
I certify that I have read this application and state that the above information is correct. I agree to
state laws relating to building construction, and hereby authorize representatives of this city to enter
inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against
may accrue against said City in consequence of the granting of this permit. Additionally, the applicant
source Section 9.18.
point
Signature Date C tk
PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS
A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS
ERY PERMIT ISSUED SHALL BECOME INVALID U LESS THE WORK ON THE SITE AUTHORIZED BY SUCH
ISSUANCE, OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR
COMMENCED.