BLD-2019-0509BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 6190 DISNEY LN CUPERTINO
APN: 375 41 017
PERMIT NO: BLD-2019-0509
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 7/21 /2019 5:52:37 PM
ISSUED BY:
VALUATION: $5000
JOB DESCRIPTION
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OWNER -BUILDER DECLARATION
declarations:
as their role compensation, will do the
licensed contractors to construct the
declarations:
for Worker's Compensation, as provided
as provided for by Section 3700 of
permit is issued, I shall not employ any
of exemption, I become subject to
work, and the structure is not intended
project (Sec. 7044. Business & Professions
or offered for sale (Sec. 7044, Business
I hereby
affirm under
I, as owner of the
Code).
penatly of perjury one of the following two
property, or my employees with wages
property, am exclusively contracting with
penatiy of perjury one of the following two
a certificate of consent to self -insure
is issued.
Worker's Compensation Insurance,
performance of the work for which this
California. If, after making this certificate
or this permit shall be deemed revoked.
V
& Professions
Code).
I, as owner of the
affirm under
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
for by Section 3700 of the Labor Code, for the performance of the
work
the Labor Code, for the performance of the work for which this permit is
person in any manner so as to become subject to the Worker's
the Worker's Compensation provisions of the Labor Code, I must forthwith
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
Chapter
as
Sections
for
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 Municipal Code, Chapter 9.12 and the Health
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous
defined by the Bay Area Air Quality Management District I will maintain
25505, 25533, and 25534.
this project.
Firm Certification No:
material. Additionally, should I use
compliance with the Cupertino
or
Code,
An EPA
Firm
No EPA
devices which emit hazardous air contaminants
Chapter 9.12 and the Health & Safety Code,
Lead -Safe Certified Renovator will be responsible
Certified
Name:
Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
lending agency for the performance
of the work which this permit is issued (Section 3097, Civil Code).
I hereby
affirm
under
No
penalty of perjury that there is a construction
�Yes
Lender's
Name:
Lender's Address:
APPLICATION CERTIFICATION
to
information is correct. I agree to comply with all city and county ordinances
enter upon the above mentioned property for inspection purposes. (We)
and expenses which may accrue against said City in consequence
regulations
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.