BLD-2020-1560BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 20990 VALLEY GREEN DR APT 635
OWNER'S NAME: KORET VC I LP
OWNER'S PHONE: Not Provided
CONTRACTOR: OWNER - BUILDER
CONTRACTOR PHONE:
DATE ISSUED 10/6/2020 2:33:27 PM
ISSUED BY:
VALUATION: $1 000
JOB DESCRIPTION
AND DRYER HOOKUPS
APT #635 - INSTALL WASHER
OWNER -BUILDER DECLARATION
three
as
with
two
-insure
this permit
revoked.
declarations:
their 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
Code).
of perjury one of the following
property, or my employees with wages
property, am exclusively contracting
of perjury one of the following
a certificate of consent to self
is issued.
Worker's Compensation Insurance,
performance of the work for which
California. If, after making this certificate
or this permit shall be deemed
& Professions
Business & Professions Code).
V
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
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
Chapter
Health
as
Sections
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
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
EPA LEAD -SAFE DISCLOSURE
Renovator will be responsible for this project.
Firm Certification No:
Firm is required for this project.
An EPA Lead -Safe Certified
Firm Name:
No EPA Lead -Safe Certified
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
application and state that the
representatives of this
against liabilities, judgements,
will comply with all non -point
above
city to
costs,
source
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I have read
construction, and hereby
harmless the City of Cupertino
the applicant understands
Signature:
.