09010128CITY OF CUPERTINO
BUILDING DIVISION PERNUT
BUILDING ADDRESS:
10295 WUNDERLICH DR TBD - TO B
OWNER'S NAME
ARCH177CUENGINEER
p c LICENSED CON7RAC10R'S DECLARATION
u I hereby affirm that 1 am licensed under provisions of Chapter 9 (commancing
Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
= ay in full force and effect. C) G
Class Lk.
Dam Comracmr t=&a. ,t
9 ARCHITECTSDECLARATION ei3vl.kv' Of cji
I undcrsland my plum shall be used as public records
�yU
= tr Licensed Professional
=y OWNER -BUILDER DECLARATION
gggy 1 hareby affirm that 1 am exempt from the Conuactofs License Law for the
i O C following reason. (Section 7M 1.5. Business and Professions Code: Any city or county
which requfrea a permit to eonsuvct, alter, improve, demallsh, or repair any suoctum
y prior to its issuance, also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's Lice= Law (Chapter 9
G (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
2. = that be is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7M 1.5 by any applicant for a permit subjects the applicant to a civil penalty of
Dot more than five hundred dollars (SMO).
❑ L as owner of the property. or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Busies
and Professions Cade: The Contractor's I == Law does not apply to an owner of
property who builds or improves thereon, and who doessuch work hi —If or through his
own employees, provided that such improvements are not intended or offered for sales If.
however. the building or improvement, is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or Improve for purpose of
sale.).
41 1. as owner of the property. am exclusively contracting with licensed conuacu ns to
nstroct the project (Sec 7044. Business and Professions Code,.) The Conuauars Li-
ccase Law does Dot apply to an owner of property who builds or improves thereon, and
who conuacts for such projects with a contractor(s)w acror(s) licensed pursuant to the Cancmrs
License Law.
❑ 1 am exempt under Sec , B & P C for this mason
Owner Dam
WORKERS COMMMATION DECLARATION
i hereby affirm under penalty of perjury are of the following declarations
❑ 1 have and wBl maintain a Certificate of Consent to self-insum for Wor ces 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 Workers Compensation insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number art:
Carrier '_4e"'� Policy NwSnk49q_�
CERTIFICATE OF EKEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ThIssection need not be completed if the permit is for one hundred doBus ($100)
or less)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any maorerso as to become subject to the Workers Compevaton
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, allrr making this Cenlfiae of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you muss
O forthwith comply with such provisions or this pacmit shall be domedd revoke
CONSTRUCTION LENDING AGENCY
F-r I hareby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued (Sec. 3097, Civ. C.)
a Q L cruices Name
L
Z e nder's Address
U 0 I certify that I have read this application and state that the above information is
LT. " cored 1 agree to comply with all city and county ordinances and state laws relating to
0 V building consuuction. and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes W (We) agree to save, Indemnify and keep harmless the City of Cupertino sgainat
93.
H ray liabilities, judgments costa and expenses which may in any way accrue against said City
U Z in comequena of the granting of this permlL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signaffirc DaeApplicanUConuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will rho applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Codc. Chapter 9.12, and the Health and Safety
Code. Section 25332(a)7
❑ Yes 'Xto
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
Cl Yes �No
1 have mad the haxandan materisis requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade. Sections =0.25533 and 25534.1 understand that If the building
does not cumandy have a tenant. that It.is my responsibility to notify the occupant of the
requirements a Certificate of Occupancy.
PERMrr NO.
D 090101-28
ITElih41T ISSUE DATE
S CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
DEMO EXISTING 814 SQ FT
Sq. Ft. Floor Area
37516019.00
5000
Required Inspections
Cc�,v) Pc�'-�1`.or� '� F�IS(��✓a""' cat- �knn� '
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy
Date -41- A --0
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class'%'' or better
Date