09060146 CITY OF CUPERTINO
BUILDING DIVISION PERT
BUILDING ADDRESS: PERMIT NO.
10410 WUNDERLI H DR TBD — "0 BE DETERMINED n9n(;n146
OWNER'S NAME: PERMIT L95UE DATE
S A CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION
UP 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Code,an my license is
y in full force and eff � RE—RF __NSTL 7/16 OSB PLYBRD OVR TOP RF.DECKNG 2"
D rig License Class Lic.f)
CF0 Date C Contractor ega- e. THICK& NAIL IT OFF W/16 D STRIP NAILS SO NEW OSB
ARC ITECTS DECLARA71ON
�<l understand my plans shall be used as public records WL STRIIGTHN RF & IT TO BE NAI LD TO THE 4X4 BEAMS
AyU
C y Licensed Professional
Rl OWNER-BUILDER DECLARATION
f I hereby affirm that 1 am exempt from the Contractor's License Law for the
y o O following reason.(Section 7031.5,Business and Professions Code:Any city or county
e which requires a permit to construct.alter,improve,demolish•or repair any structure
Z y 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 LAeense Law(Chapter 9 Sq.Ft.Floor Area Valuation
yH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y R$R that he is exempt therefrom and the basis for the alleged exemption.Any violation of $6000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mete than rive hundred dollars(s500). 37517003 . 00
❑I,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 does not apply to an owner of Required Inspections
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
construct the project(See.7044.Business and Professions Code:)Tile Contractor's Li-
cense Caw does not apply to an owner of property who builds or improves thereon,and•
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for worker's compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Worker's ort�ypena. ]n u ce carrier and Policy number am:
Cartier 1 Polity No.:
CERTIFICATE OF EXEMPTION FROM RS'
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 Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performarax of
lx .7 the work for which this permit is issued(Sec.3097.Civ.C.)
:44 1,Q Le dee Name
]z Lender's Address
V 0 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 misting to
0 V building construction,and hereby authorise representatives or this city to enter upon the
W above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r r rA liabilities,judgments,costs and expenses which may in any way accrue against said City
V z in consequence of the granting of this permit.
r"h
Re-roofs
Signature of App is t/Conr ate
HAZA o s ALS D[ LOSURE Type of F.00f
will the applicant or future ilding 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.
❑Yea 0<
Will the applicant or futon building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardous air contaminants as defined by the Bay Area Air Quality Management all new IT aterials for inspection.
District?
❑Yes ,8'9u
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25 3 and 25534.1 understand that if the building
does not curtcnlI have a ten that it'. y responsibility to notify the occupant of the
D te All roof coverings to be Class''"or better