BLD-2020-0548BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: Must Provide Permit Number in
OWNER'S NAME: Not provided
OWNER'S PHONE: 408-252-4451
CONTRACTOR: MUST RETRIEVE DATA.
CONTRACTOR PHONE:
DATE ISSUED MUST RETRIEVE DATA
ISSUED BY:
VALUATION:
JOB DESCRIPTION
MUST RETRIEVE DATA.
OWNER -BUILDER DECLARATION
two declarations:
as their role compensation, will do the work,
with licensed contractors to construct the project
two declarations:
-insure for Worker's Compensation, as provided
as provided for by Section 3700 of the Labor
this permit is issued, I shall not employ any person
of exemption, I become subject to the
revoked.
and the structure is not intended or offered for sale (Sec. 7044, Business
I hereby
affirm under penatly of perjury one of the following
I, as owner of the property, or my employees with wages
Code).
& Professions
(Sec. 7044. Business & Professions Code).
I, as owner of the property, am exclusively contracting
affirm under penatiy of perjury one of the following
I have and will maintain a certificate of consent to self
for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,
I certify that in the performance of the work for which
laws of California. If, after making this certificate
with such provisions or this permit shall be deemed
I hereby
for by Section 3700 of the Labor Code, for the performance of the
work
Code, for the performance of the work for which this permit is
in any manner so as to become subject to the Worker's
Worker's Compensation provisions of the Labor Code, I must forthwith
V
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
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 under
the Cupertino Municioal Code. Chatter 9.12 and the
with
equipment
Municipal
Health & 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.
for this project.
Firm Certification No:
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
Certified
V
CONSTRUCTION LENDING AGENCY
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 construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
above information is correct. I agree to comply with all city and county ordinances and state laws relating to building
city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
source regulations per the Cupertino Municioal Code. Section 9.18.
I certify
construction,
harmless
the
Signature:
that I
the
applicant
.