BLD-2021-1188BUILDING PERMIT
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: MUST RETRIEVE DATA.
APN:
PERMIT NO: Error retrieving data or unable to retrieve all required fields.
Contact rosss@cupertino.org for assistance
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.
LICENSED CONTRACTOR DECLARATION
of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
LICENSED
MUST
LICENSED
EXP
MUST
I hereby
force
I hereby
MUST RETRIEVE DATA.
CLASS:
RETRIEVE DATA
NO: MUST RETRIEVE DATA.
DATE:
RETRIEVE DATA.
affirm that I am licensed under the provisions
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 declarations:
self -insure for Worker's Compensation, as provided
as provided for by Section 3700 of the
this permit is issued, I shall not employ any person
of exemption, I become subject to the
revoked.
for by Section 3700 of the Labor Code, for the performance of the
work
Labor 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
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issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
under 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
the 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
Code, Sections 25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety
EPA LEAD -SAFE DISCLOSURE
for this project.
Firm Certification No:
project.
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this
Certified
V
CONSTRUCTION LENDING AGENCY
construction 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
No
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Lender's
Name:
APPLICATION CERTIFICATION
the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building
this 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,
-point source regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I
construction,
harmless the
the applicant
Signature:
4—>C1
have read this application and state that
and hereby authorize representatives of
City of Cupertino against liabilities, judgements,
understands and will comply with all non
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.