06090059BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'
PHONE:
ARCHITECf/ENG[NEER:
LICENSED CONTRACTOR'S DECLARATION
1 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
n full force and effect.
icensc Class Lic.#
Date Contractor
ARCHITECI-S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hcrchy affirm that 1 am exempt from the Contractor's License Law for the
'ollowing reason. (Sccdon 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
irior to its issuance, also requires the applicant forsuch permit to file a signed statement
ghat he is licensed pursuant to the provisions of the Contractor's Liccnsc Law (Chapter 9
(commencing with Section 701X)) of Division 3 of the Business and Professions Codc) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 703).5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1, 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, Business
and Professions Code: The Contractor's License Law docs 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 forsale. 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.).
❑ 1, 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 docs 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 Contractor's
License Law.
❑
� Date 6 . )1
WORKER'S COIPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Codc, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Sccdon
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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Mis section need not hecompicted if the permit is forone hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to bccomc subjcct to the Workers' Compensation
Laws of Califo
Certificate of Exemption, you should
become subject to the Worker's Com. ion 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 (See. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 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 consuuction. 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 accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
E] Yes No
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?
❑Yes No
I have read the hazardous atcrialsrequirements under Chapter 6.95ofthe Cali for-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occu ancy.
,
Owner or authorized agent Datc
AHUVA & NILL GELBLUM I PERMIT NO. 06090059
10405 WUND
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
Job Description
BUILDING PERMIT INFO
REVISION- REMOVE NEW FAMILY ROOM & ADJACENT BAT
ALSO EXISTING ROOF LINE WILL REMAIN OVER THE EX
ING MASTER BED, PORCH & GARAGE. ORIGINAL 060100
Sq. Ft. Floor Area Valuation
$190000
APN Num
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
Type
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.
Date
All roof coverings to be Class "B" or better