07020134 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C ' ,GTO IN�4�MATI�N.'
PERMIT NO.
BUILDING ADDRESS:
10405 WUNDERLICH DR AHUVA & NILL GELBLUM 07020134
PERMIT ISSUE DATE
-`vNER'S NAME:
BUILDING PERMIT INFO
ARCHI'IECTIENGINEER: BLDG EO PLUMB ME�CH
REVISION - REVISING EXISTIN
i p p LICENSED CONTRACTOR'S DECLARATION ROOF rTT Job Description
v1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
z IJ with Section 7000)of Division 3 of the Business and Professions Codc,and my license is
h=y in full force and effect.
? License Class Lic.#
G Dam Contractor
ARCHITECTS DECLARATION
7 d I understand my plans shall be used as public records
>yU
'U.y Licensed Professional
a OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
co following reason.(Section 7031.5,Business and Professions Codc:Any city or county
`<m ff 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 rile a signed statement Valuation
Z> p q,Ft.Floor Area
a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
r=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
ythat he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500).
❑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 Required Inspections
and Professions Code:The Contractor's License Law does 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 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
sa J.
!,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 contractors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
•ner Date
DECLARATION
I hereby affirm under pcnal[y o perjury one of the following
declarations: -
❑I have and will maintain a Certificate of Consent to self-insum 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.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Codc,for the performance of the work for which this permit is issued.
My Worker's 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 to b'ct Workers'Compensation
Laws
Exemption,you should
become subject to the Worker's Compensatio provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
Fes, I hereby affirm that there is a construction lending agency for the performance of
(Y r7 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
a, Z Lender's Address
U C) I certify that I have read this application and state that the above information is
ft. correct.I agree to comply with all city and county ordinances and state laws relating to
rJ- U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
LL (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 �--
U z in consequence of the granting of this permit. Date
r y APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR R U TIONS.
Re-roofs
Type of
HAZARDOUS MA ALS DISCLOSURE yp
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
,le,Scction 25532(a)? �/ All roofs ;hall be inspected prior to any roofing material being installed.
Cl Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof i 3 installed without first obtaining an inspection,I agree to remove
emit hazardous air contamin7N.
defined by the Bay Area Air Quality Management all new rr aterials for inspection.
District?
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of thc Califor-
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
req'rements which must be mel . to issuance of a Certificate oyQef�! Signature of Applicant Date
`/��f t/ r All roof coverings to be Class"B or better
atc