BLD-2023-2045_SignedPermitBUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: APN: PERMIT NO:
OWNER’S NAME: OWNER’S PHONE:
CONTRACTOR: CONTRACTOR PHONE:
DATE ISSUED: ISSUED BY: VALUATION:
JOB DESCRIPTION:
LICENSED CONTRACTOR’S DECLARATION:
CONTRACTOR: LICENSED CLASS: LICENSED NO: EXP DATE:
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
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, as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain Worker’s Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the
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 not employ any person in any manner so as to
become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to
the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or
handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area
Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code,
Sections 25505, 25533, and 25534.
EPA LEAD-SAFE DISCLOSURE
An EPA Lead-Safe Certified Renovator will be responsible for this project.
Certified Firm Name: _____________________________________________ Firm Certification No: ____________________________
No EPA Lead-Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work which this permit is issued
(Section 3097, Civil Code).
Yes No
Lender’s Name: ________________________________
Lender’s Address: _______________________________
APPLICATION CERTIFICATION
I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state
laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection
purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgements, costs, and expenses which may
accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code, Section 9.18.
Signature ___________________________________________ Date ______________________________
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.
10398 HENEY CREEK PL 342 48 036 BLD-2023-2045
JONES BERNICE G TRUSTEE
PLUMBTREE PLUMBING AND ROOTER INC
Jasmine Archbold 17000
PLUMBTREE PLUMBING AND ROOTER INC 1073826 03/31/2025
Sep 14, 2023
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Sep 14, 2023