BLD-2021-0287BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 19735 DRAKE DR Cupertino
APN: 316 32 037
PERMIT NO: BLD-2021-0287
OWNER'S NAME:
JOB DESCRIPTION
SF); REPLACE AND RELOCATE FURNACE TO ATTIC
KITCHEN REMODEL (380
OWNER -BUILDER DECLARATION
three
as their
with
two
to self -insure
Insurance,
which this
certificate
revoked.
declarations:
role compensation, will do the work, and the structure
licensed contractors to construct the project (Sec. 7044,
is not intended or offered for sale (Sec. 7044, Business &
I hereby affirm under penatly
I, as owner of the property,
Professions Code).
of perjury one of the following
or my employees with wages
property, am exclusively contracting
of perjury one of the following
a certificate of consent
is issued.
Worker's Compensation
performance of the work for
California. If, after making this
or this permit shall be deemed
Business & Professions Code).
I, as owner of the
affirm under penatiy
I have and will maintain
for which this permit
I have and will maintain
I certify that in the
laws of
with such provisions
I hereby
declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
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
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
V
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:
project.
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this
Certified
CONSTRUCTION LENDING AGENCY
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 a
No
V
Lender's
Name:
APPLICATION CERTIFICATION
the above
this city
-point
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
.