07010126:)2
7- C
CITY OF CUPERTINO PE�Y�:�
BUILDING DIVISION
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BUILDING ADDRESS:
PERMIT NO.
10591 WUNDERLICH DR
TH GENERAL CONSTRUCTION INC
07010126
SANITARY NO. CONTROL NO,
ARCHrMC IENGINEER:
BURRING PERMIT INFO
DEMO SFDWL TH GENERAL
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under previsions of Chapter 9 (commencing
, _ . , . „
withSection 70D0) of Division 3 of the Business and Professions Code, and my license is
in full force and effect ®/Z2�/
License Class Lic. i�%T—
Dale O Contractor� i_—
ARCH L-rS DEC19f1iF.TTON
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
i hereby arm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: 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 file a signed statement
that be is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hhmdmd dollars (S500).
❑ 1, as owner of the property, or my employees with wages as thew sole compensation,
Required Inspections
win do the work- and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Code The Contractors License Law des not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. 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.).
❑ L as 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 contractor(s) licensed pursuant to The Contractors
License Law.
❑ I am exempt under Sec. . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pFrjury one of the following declarations:
i have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sati as provided for by Section 3700 of the Lobar 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 carrier and Policy number are:
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)
Of Icst)
i certify that in the performance of the work for hied hs permit is isle jshall not
employ any
. you should
become subject to the Workeei Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
I
' CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
-
Lenders Name
,
Lenders Address
j 1 certify that 1 have read this application and state that the shove information is
' correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize mpresentatives of This city to enter upon the
i ahove-mentioned property for inspection purposes.
_
(We) agree to save, indemnify and keep harmless the City or Cupertino against
j liabilifle& judgmems. costs and expenses which may in any way accrue against said City
' in consequence of the granting of this
APPLICANT UNDER ANDS L.L COMPLY W ALL NON -POI
/"`
Issued
WBI the applicant or future building occupant store or handle hazardous material
as denned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes 'Zo
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 defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
[] Yes u
Idavemad the hazardousmaterials mquirem under Chapter &95oftheCalifor-
nia Health & Safety Code, Sections 25505. 534. I hmdcrstand that if the building
Jaen not currency ha a that ntttponsi 'icy "ocfy the occupant of the
-
requiremcntswhi .
Signature of Applicant Date
All roof coverings to be Class "B" or better
Own
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