BLD-2021-0656BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10320 STERN AVE Cupertino
APN: 375 14 032
PERMIT NO: BLD-2021-0656
OWNER'S
JOB DESCRIPTION
BATH (180 SF) - SAME LAYOUT AS EXISTING
REMODEL MASTER BATH AND GUEST
LICENSED CONTRACTOR DECLARATION
Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
LICENSED
B GENERAL
LICENSED
EXP
05/31/2022
I hereby
force
I hereby
URBAN INTERIOR DESIGN
CLASS:
BUILDING CONTRACTOR
NO: 1038865
DATE:
affirm that I am licensed under the provisions of
and effect.
affirm under penatiy of perjury one of the following
I have and will maintain a certificate of consent to
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
three
self -insure
this
revoked.
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
permit 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
V
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
under
the Health
Code,
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
the Cupertino Municipal Code, Chapter 9.12 and
V
with
equipment
Municipal
& 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.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety
EPA LEAD -SAFE DISCLOSURE
will be responsible for this project.
Firm Certification No:
is required for this project.
An EPA Lead -Safe Certified Renovator
Firm Name:
No EPA Lead -Safe Certified Firm
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
and state that
representatives of this
liabilities, judgements,
comply with all non
the above
city
-point
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
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 Municipal Code, Section 9.18.
I certify that I
construction,
harmless the
the applicant
Signature:
have read this application
and hereby authorize
City of Cupertino against
understands and will
.