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CITY OF CUPERTINO 7�Ia,�001
BUILDING DIVISION PEl\LY11Ta•.r
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BUILDING ADDRESS:
PERMIT NO.
10410 WUNDERLICH DR
NV CONSTRUCTION
09040073
OWNER'S NAME:
PERMIT ISSUE DATE
SXWA 0. CONTROL NO.
(925) 408-7019
ARCHITECT/ENGINEER:
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect. g y y 3
RMDL KTCH (110) , BTH (9 0) , RE PLC
7
License _ - CCont�r am t.9
FURNC, NON-STRCTRL, RPLC WNDWS LIKE 4 LIKE; NO RE -RF
ARCHITECTS DECLARATI N
I understand my plans shall be used is public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason- (Section 70315, 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 We a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
5 5 0 0
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy e
p y TYp
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
37517003 .00
❑ L, as owner of the property, or my eroployces with wages as their sok compensation,
Required Inspections
will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions coda The Contractor's License Law docs not apply to an owner of
property who builds or improves thetuon, and who does such work himself or through his
own empkyces, provided that such Improvements ate not intended or offered for sale If,
however, the building or improvement Is sold within one year of completion, the owner -
builder w01 have the burden of proving that he did not build or improve for purpose of
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y �s 7 iiV U C � 0,J
sale.).
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❑ 1, as owner of the property, are exclusively contracting with licensed conuactors to
construct the project (Sec. 7D44, Business and Professions Code:) The Contractors 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 Conuamoes
LIC. Law.
❑ 1 am exempt under Sec B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers 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 carrier and Policy number arc_
Carrier:/4Cco/Lf) PolicyNo.:OCIC JS0ZS- PC4
XSV
CHRTTFICATE OF 1. FMTFTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred doll= (51110)
or less.)
I certify that In the performance of the work for which this permit is Issued, I shall not
employ any person in any manner so as to become subject to the Workers' Comppnsadon
Lawof California. Date
Appls icant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers 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 affirm that there is a construction lending agency for the performance of
the work for which this permit Is issued (Six. 3097, CW. C.)
Lenders Name
,
Lenders Addtrss
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 authorize representatives 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
liabilities, judgments. costs and expenses which may in any way aexnm against said City
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of the granting that permit
A
APPLICPLIC ANTNT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
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Re -roofs
—
Type of Roof
Si nature of Applicarit/ContracidY Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Store or handle h— ous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
2ss32(a)?
Code. Section�No
❑ Ya
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
Will the applicant or future building Occupant use equipment or devices which
emit hazardous air contaminants as de0ned by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes fNo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534. I understand thinif the building
does not cvnently have a ten=et that It is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
4V 69 D q-ty-10 i
All roof coverings to be Class'%" or better
Owner '
or authorized agent Dam