09060139 CITY OF CUPERTINO ���T
BUILDING DIVISION PERMIT4' "TW
.
BUILDING ADDRESS: PERMIT NO.
10340 WUNDERLICH DR HIROSHI
PERMIT ISSUE DATE
OWNER'S NAME:
S CONTROL NO.
(
BUILDING PERMIT INFO
ARCHITECI/ENGINEER:
BLDG ELECT PLUMB MECH
u0p LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70(10)of Division 3 of the Business and Professions Code,and my license is
= H ADDITIPIG PARTITION WALL 10"6 LENGTH $" HEIGHT
in full force andeffecL
z License Le.B
DWITH SLIDING DOOR. REMOVE RAISED FLOOR AND ASIAN
E:,O Dae Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he Used as public records STYLE SLIDING DOORS NON—STRUCTURAL
r U
y Licensed Professional
p 3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
Pi 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 Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
xi (commencing with Section 7000)mf Division 3 of the Business and Professions Code)or8500
y 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 civil penalty of APN Number Occupancy Type
not more than five hundred dollars($5M). 375170'-0 . 00
0 mit owner of the property,or my employees with wages as their sole compensation.
VM do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q p
prop ny 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
construct the project(See.7044.Business and Professions Code:)The Contractors Li-
cense Caw 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
~' Z
Owner� Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Compcn-
.don,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's 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. 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
NOTICE TO AP ,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z "' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
GY, the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lenders Name
Z Lenders Address
U C) I certify that 1 have read this application and state that the above information is
(L r" correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
L3 t (We)agree to save,indemnify and keep harmless the City of Cupertino against
,..0 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
APPLICANT UNDERSTANDS AND WILL COMP WITH ALL NON-POINT Issued by:
SOURCE . '
Re-roofs
Signaufi of Applicandcontractor Dae
HAZARDOUS MATERIALS DISCLOSURE Type of F.00f
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)? All roofs shall be inspected prior to any roofing material being installed.
fi
❑Yes leo
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
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new Materials for inspection.
strict?
0Yes 50roL,
1 have read the havarlous 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 ismy responsibility to notify the occupant of the
regmi
D