BLD-2021-0301_SignedPermitCITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10280 VICKSBURG DR APN:369 14 010
PERMIT NO: BLD-2021-0301
OWNER'S NAME: YUAN YIQIN
OWNER'S PHONE:
CONTRACTOR: CAL STATE CONSTRUCTION
CONTRACTOR PHONE:
DATE ISSUED: Dec 10, 2021 ISSUED BY:Jasmine Archbold VALUATION: 150000
JOB DESCRIPTION: ADDITION TO 1-STORY SFD - (300 SF) LIVING ROOM BETWEEN THE DETACHED GARAGE AND THE MAIN HOUSE;
REMODEL (3) BATHROOMS - (151 SF); REMODEL KITCHEN - (152 KW); REMODEL OTHER - (883 SF) RELOCATE AND
REPLACE WATER HEATER WITH TANKLESS ; MOVE WASHER DRYER FROM LAUNDRY ROOM TO GARAGE; FROM
INTERIOR CLOSET RELOCATE THE FURNACE TO GARAGE; ; RELOCATE AND UPGRADE ELECTRICAL PANEL TO
GARAGE - (200 AMP); IN THE GARAGE DEMO THE INTERIOR WALL AND CONVERT 2-SINGLE GARAGE DOOORS TO (1)
CAR GARAGE DOOR
LICENSED CONTRACTOR'S DECLARATION:
NO: 612007 EXP DATE: 07/31/2022
7000) of Division 3 of the Business & Professions
CONTRACTOR: CAL STATE CONSTRUCTION LICENSED CLASS: LDING L LICENSED
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 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.
✓ 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, I 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:
❑ An EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified Firm Name: Firm Certification
✓ 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 7, Civil Code).
Yes ✓❑ 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
understands and will comply with all non -point
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,
accrue against said City in consequence of the granting of this permit. Additionally, the applicant
source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Andy Nguyen Date Dec 10, 2021
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.