BLD-2021-0445BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 21498 METEOR DR Cupertino
APN: 326 44 001
PERMIT NO: BLD-2021-0445
OWNER'S NAME: WANG WEN-YUAN ET AL
OWNER'S PHONE: 4083483459
JOB DESCRIPTION
PURPOSES ONLY - (336 SF)
DEMO POOL FOR LANDSCAPE
OWNER -BUILDER DECLARATION
of the following three
with wages as their
contracting with licensed
of the following two declarations:
of consent to self -insure
Insurance, as
work for which this permit
making this certificate of
be deemed revoked.
declarations:
role compensation, will do the work, and the structure
contractors to construct the project (Sec. 7044,
is not intended or offered for sale (Sec. 7044, Business
I hereby
affirm under penatly of perjury one
I, as owner of the property, or my employees
Code).
& Professions
Business & Professions Code).
I, as owner of the property, am exclusively
affirm under penatiy of perjury one
I have and will maintain a certificate
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the
laws of California. If, after
with such provisions or this permit shall
I hereby
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
is issued, I shall not employ any person in any manner so as to become subject to the Worker's
exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
issued.
V
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
under
9.12 and the Health
Chapter
as
Sections
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
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
EPA LEAD -SAFE DISCLOSURE
will be responsible for this project.
Firm Certification No:
for this project.
An EPA Lead -Safe Certified Renovator
Firm Name:
No EPA Lead -Safe Certified Firm is required
Certified
V
CONSTRUCTION LENDING AGENCY
there is 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
No
V
Lender's
Name:
APPLICATION CERTIFICATION
state that the above
of this city
judgements,
with all non -point
lissil
to enter
costs,
source
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I have
construction, and
harmless the City of
the applicant understands
Signature:
read this application and
hereby authorize representatives
Cupertino against liabilities,
and will comply
.