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07090043 CITY OF CUPERTINO T� 7- BUILDING DIVISION PERMIT BUILDINGADDRESS: PERMIT NO. 10405 WUNDERLICH DR AHUVA & NILL GELBLUM 07090043 OWNER'S NAME: PERMIT ISSUE DATE AHUVA & NILL GELBLUM 10405 WIJNDERLICH DR 09/10/2007 NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH p p LICENSED CONTRACTOR'S DECLARATION Job Description mI hereby affirm that I am licensed under provisions of Chapter 9(commencing Z� withScction 7000)ofDivision 3ofthe Business and Professions Code.and mylicense is INSTALL TEMPORARY POWER POLE. ":'D4 H in full force and effect. License Class Lic.# t- Date Contractor ARCHITECTS DECLARATION i < I understand my plans shall be used as public records >yU w Licensed Professional y OWNER-BUILDER DECLARATION >- 1 hereby affirm that I am exempt from the Contractor's License Law for the .00 following reason.(Section 7031.5,Business and Professions Code:Any city or county ${i which requires a permit to construct.alter.improve,demolish,or repair any structure r ZIn prior to its issuance,also requires the applicant for such permit to file a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $150 r3. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a cavil penalty ofNumber Occupancy Type not more than five hundred dollars(5500). 3 7 5 1 6 0 3 1) �� [11,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.70".Business Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of q p 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.). I.as owner of the property,am exclusively contracting with licensed contractors to rb trust the project(Sec.7044.Business and Professions Code:)The Conttaaoes 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. 0 I am exe under Se .B&cP c ror this reason Owner Date 11► o� WO KERS CO SATION DECLARATION 1 hereby affirm under penalty of perjury one of Ude following declarations: n 1 have and will maintain a Certificate of Consent to self-insum 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 are: Cartier. 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 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 Workcrs'Compensation Laws of Califit,Date Applicant NOTICE TO PP CANT:If,after 41161iff this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code.you must O forthwith comply with such provisions or this permit shall be deemed revoked Z— CONSTRUCTION LENDING AGENCY Htom. I hereby affirm that there is a construction lending agency for the performance of fYr the work for which this permit is issued(Sec.3097,Civ.C.) aA Lenders Name Z Lcndees Address U 0 1 certify that I have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relating to Ubuilding construction.and hereby authorize representatives of this city to enter upon the Uabove-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against 'F liabilities,judgments,costs and expenses which may in any way accrue against said City U,Z in consequence of the granting of this permit. Date ►-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: C SOUR GULATIONS. Re-roofs Signature of Applicant/Contractor Clue HAZARDOUSATERIALS DISCLOSURE Type of R)of l Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? y All roofs,hall be inspected prior to any roofing material being installed. 0 Yes Vo Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new in iterials for inspection. District? [I Yes No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements hmustbe et riorw' manccofaCertifrcate°foe Signature �fApplieant Date All roof coverings to be Class"B"or better Owner or authorized agent are CITY OF C'UPERTINO 0? 09 O o`f-3 a(T TEMP POWER CUPERTINO PERMIT APPLICATION FORM APN# 3),5 1 r Date: Buildingddress: , �o d5 (Ai �2 0 22 /917M9 moo/ rowner'sNa Phone #: Contractor: P lone: _ License #l: I&AQ AD Contact: Phone: Cupertino Business License #: Building Permit Info: Elect Job Description: ResidentialCommercial ❑ Cost of Project: -05. 0 Qty. if Applicable Fee ID Fee Description Fee Group BTEMP Temporary Power ELECTRICAL EPERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Bu 3mess License BUILDING CITY OF CUPERTINO 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk.: Lot: APN 37E16030. 00 DATE ISSUED. . . . . . . : 09/10/2007 RECEIPT #. . . . . . . . . : BSC00002596 REFERENCE ID # . . . : 07C90043 SITE ADDRESS . . . . . : 10405 WUNDERLICH DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : AHLrVA & NILL GELBLUM ADDRESS . . . . . . . . . . : 10405 WUNDERLICH DR CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : DANA AHUVA GELBLUM CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : AHIVA & NILL GELBLUM ADDRESS . . . . . . . . . . : 10405 WUNDERLICH DR CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY 1,MOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- ------ ---------- ---------- ---------- BTEMP FLAT RATE 1. 00 62 .10 0. 00 62 .10 0. 00 EPERMITFEE FLAT RATE 1. 00 40.79 0. 00 40.79 0. 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 102 .89 0. 00 102 .89 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 102 .89 AMER EXP --------------- TOTAL RECEIPT 102 .89 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL Community Development 10300 Torre Avenue � s. Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ';UPERTINO Buildin Department JOB ADDRESS: PERMIT # O O 3 ,/0 `-( O� 1,z� Dr6) ,7 OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Si::,,-nature Date Please check applicable subcontractors and cam )lete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ,D) - 14067 Owner/Con actor Signature Date