05090179 CITY OF CUPERTINO :f':ns'..s:.m.,,<a +er,.:.i;:f"= •sr.;rr+:• .`. •s.' s
BUILDING DIVISION PERMIT =<CONTRACTUR,INF..ORMATION"s.=
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BUILDING ADDRESS: PERMIT NO.0 5 0 9 017 9
22036 ACACIA WAY
NER'S NAME: PERMIT ISSUE DAM
' JUSTIN MOZART 02/10/2006
E: SANITARY NO. CONTROL NO.
ARCHITEC IENGINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
30O` LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 hereby art Nn I am limased under provisions of Chapter 9(commencing
with Section 7088)of Division 3 of due Business and Profawons Code,and my hearse is
in mu force and effect. SFDWL-2 STORY 2436 ' GARAGE 420 '
License Class Lk.a
F Date Cawrmmr
eq ARCHITECTS DECLARATION
L 22 1 understand my plans shall be used An public records
kQ Lkemed Prefcat...I
OW NER-BUILDHR DECLARATION
1 hereby affirm that 1 em exempt from the Contractors License Law for fie
HO following mason.(&oil 7031.5,BamAASS and Professions Cade:Any city or county
uS K which requires a Permit to conswcl,alter,Improve,dcarclon.or repair any structure $545885
_jr pd.,to its i....cc.also acquires the applicant forsuch Permit o file asigned statement
<
that bets licensed pursuant to the provision or the,Camsacter''sLicense Law(Chapter 9 Sq. Ft.Floor Area Valuation
y�s (eommcnung with Session 7000)af DivtsianJef the Boninev and Prafesuans Cade)or
dot be u exempt therefrom and the buts for the alleged ea capdon.Any violation
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of D 14FW>51Mrflber u u Occupancy Type .
not more than five hundred delta.($500).
0 1,As owner of the property,or my employees with wages As their sole compensation,
will do the work sad the eVUClua is not intended or offered for ask(Sec.7014.Business
o Required Inspections Professins Code:The Common,Lmmm law does sat apply m in Owner of
property who builds or Improves thereomand whodoessuch work himself wth ough his
own employe.,provided Nat such improvements art ImUmeMed Ora @red far ale IL
however,the building or improvement is said within hem year of compledon.the owner
builder wiH hive the burden of proving that be did sat Wild or Improve for purpose of
ale.).
O 1,as owner or the property,am exclusively contracting with licensed conuecmrs to
construct the pmjca(Sec.7004,Business and Professions Cade:)The Contractors U.
tense law does not apply in an owner of property who Wdda or improves demon,and,
who contracts for such projects wnth a matranods)licensed purmant m the Contractors
Licence law.
0 1 am exempt under Sec. B k P C far that reasa
10, DSm 2-(1)T�
WORKER'S M P.NSATION DECLARATION
1 bereby S1nda on, pmW t 1 perjury am of de following declarations:
0 I low and will maintain aCeniftwte of Consent to self-insum fw Workers Compen.
ono.,a provided far by Section 3700 of the labw Code,for the performance of ma:
wart far which this permit is trued
0 1 haw and will maintain Workeh Compensation Insurvtm,As required by Secton
3700 of the labor Cade,for the performance of the work far which this Permit is issued.
My Workers Compensation Wuanm carrier and Policy number ate:
Carder: Policy N- ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secdm need notbeco nplemd If the permit is from hundred doaare(SI00)
or ICU.)
1 cendy,let to the performance of the work for which this permit Is issued.l shall not
employ anyperson in any mannersa m meylkect to the Workers'Compensation
Laws or lifirmia.Dal- "°
ApPhe
NOTICE PPLICANT:If.after kln�h u Ccnificate of ascription,you should
become sub t to the Woker's Compensation pmisiom Or the labor Code.you am
.J O faMwith comply with such provisions at Nis permit shall be dcemed mvnked.
z 51 CONSTRUCTION LENDING AGENCY
[-e I hereby affirm that there is a construction lending agency for the performance of
a r7 the work fur which Nis permit is issued(Sac.3077,Ch,C.)
Vj Q Landers Nam-
C. Lender's Addma
U O 1 certify that I haw and this application and sum that the move information ts
ITr F contact.I agree in comply with all city and county ordinenms and auk laws¢lasing to
0U building convection,and hereby suthorim representatives of this city to enter upon the
14 show-mentioncil property for Inspection purposes.
P. (We)agree to taw,indemnify and keep harmless the City of Cupertino against
pj limilnles,judgmcnu,cons,and expenses which may In any way accrue against said City
U 7 in consequence of the panting of this Permit.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULAT10�� .— 10 eb _
Re-roofs Q
slg mOTApphcaVCa r Date
HAZA US MATERIALS DISCLOSURE Type of Roof
Will dm Applicant or future building occupant slam arhandle haardous material
As defined by the CupeNno Municipal Code.Chapter 9 12,and the Health and Safety
Section 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
Oven ON.
Will the applicant or future budding=upon,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmh humdous air contaminants an defined by the Bay Area Air Quality Management all new materials for inspection.
District?
DYcs ONo
I haw mail the haeudmo materials requirements under Chapter 6.95 ofdm Califon
na Health k SafctyCodc,Sa4ms 25505,25533 and 25534.l understand NU if the budding
does not currently hest a¢mart.that Is u my msponsihility in notify dm meupant of de
roqulsemems which mum be m s pdor m issuance of a Ocruficam of Occupancy.
tic = =�t40_� Signature of Applicant Date
own l r aeaada<d�ecmt 1— D,te All roof coverings to be Class"B"or better L.