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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
.�RLGfi�diMeAaTIiY
s:
BUI 1 G FSS:
PERMIT NO.
WUNDERLICH DR
TBD - TO BE DETERMINED
07090201
OWNER'S NAME:
FERMrr nUE DATE
SAID KARKOUTI
10/08/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCfiITECr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70D(Y) of Division 3 of the Business and Professions Code. and my license is
DEMO - S F D
in full form and effect
License Class Lle. M
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area -
Valuation
that pursuant provisions
with Section 70D0) of Division 3 of the Business and Professions Code) Or
$(commencing 1 5 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (S500).
37516031 : U
❑ I. as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (sec. 7044, Business
and Professions Code The Contractor's License Law does not apply to an owner of
q P
property who builds or improves thereon, and who does such work himself ter through his
awe employees, provided that such improvements art not intended or offered far sale, If.
however, the building or improvement is sold within one year of comp"on, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
axle.
I, es owner of the property, am exclusively contracting with licensed contractors to
.
construct the project (Sec 7044. Business and Professions Code) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon. and.
who contracts for such projects with a eontractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exe, p under S , B & P C for his reason
~
Owner Date
-
'WOUKERS,ENSATIO DECIARATIO -'
I bemby &Turn under penalty of perjury one of the following declarations.
❑ I have and will maintain a Certificate of Consent to self -insure for Workds Compen-
sation, 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 required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
'
My Worker's Compensation Insurance carrier and Policy number am:
-
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit Is for one hundred dollars ($100)
or less)
I certify that in the pp fo ante o work for wh' ermit is ssucd, I shall not
chi
employ any person i1 manna so to bee m object kite W rs'!mpemdon
Laws of California.
Applicant
NOTICE TO A : 1 , after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby afrrrm that there is it construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. Q
'
Lcndces Name
Lender's Address
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 authorim mp,eseniauves 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
j liabilities, judgmens, toss and expenses which may in any way accrue against said City
.
' in conseque o the granting of this per )L
ST(NDS N IL OM ITH ALL NON -POINT
( APPLICW'1Nf
Issued by: Date
SOURC
U Lt �-f
Re -roofs Z�
Type of Roof
Sig of Applicam/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
W;fl the applicant or future building occupant store or handle hazardous material
as deleted by the Cupertino Murrici odc, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
C] Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as de0n>ed by the Bay Area Air Quality Management
all new materials for inspection.
Disuict7
❑Yee 0
1 have it a hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & et Codc, Sccuons 25505. 25 3 anJ 25534. understand Lhat if ft building
does not c n have t,�it ' yponst notify the occupant of the
requiremtn hick reeli -ofa epcineofOccupan
Signature Date
~-U
All roof coverings to be Class " B" or better
Owrtu
or aulhorvLd agent Dare