05090182 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONPRACTOWINFC)TtMATION-.".
BUILDING ADDRESS: PERMIT NO.0 5 0 9 018 2
10977 ArArTA WAY
fNER'S NAME: PERMIT L95UE DATE
I JUSTIN MOZART 02/10/2006
E: SANITARY NO. CONTROL NO,
ARCHOECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
2081 LICENSED CONTRACTOR'S DECLARATION Job Description -
rg u 1 her am hereby M.Nat 1 lionscd under provisions of Chapter 9(Commencing
with Sccion 7")of Division 3 of the Busineaaand Professions Codc.and my license is
3 mmnmmemde e SFDWL-2 STORY 2436 ' /GARAGE 420 '
3cii q Z Liewde Class Lic.0
Dam CMuhm,r
9 ARCHITECTS DECLARATION
i understand my plans shall W used as public mcord
9C Licensed Pmfesstnnel
OWNER-BUILDER DECLARATION
<I I hereby affirm that I am exempt Irwin the Conorctor's Licenx Lew for the
a 8 following mason (Section 7031.5,Business and Professions Code:Any city or county
$ which rcquims a permit m eonswm,e1mr,improve,dcreoli.h.Car mpA,any RruCmm $54S885
priorm its issuance,also requires Me applicant fanuch permit,.Ill ca.igned statement
E that he is licensed pursuant to Me previsions o f the Contrxmr's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
y F`$ (commencing with Section 7000)of Division 3 of the Business and Prmfcuinm COM)or
that he is exempt Mem(rom and Me burs for the alleged exemption,Any violation of
Section 7031.5 by any applicantfor a permit subjects the applicant be a civil penalty of -5API'V'N"p-P, U Occupancy Type
not mom than live hundred dollars($500).
❑I,as owner of the property,or my employees,with wages as their sole compensation,
will do the work,and the structure Is intended or o @red Our sale(Sm.7044,Business Required Inspections
and Professions Code:The Convexities License Law dos not apply m an owner of q P
property who builds or i m prove thereon,end who does suc h work himself or through his
own employers,provided tat such Improvements we not intended or offered for sale.If.
however,Me building or improvement Is amid within one year of completion.the owner-
builder will have she burden of proving Met M did not Wild tar Improve for purpose of
sale.).
❑1,as owner of Me property,am excludively contract,with licensed cuntmemrt m
construct the pmjen(Sec.7044.Business and Psmommu s Code:)The Communes U-
corue Law dos not pply in an ownm of property who Wilds or improve thereon,and
who contracta for ouch projects wide is comnmor(q licensed pursuant to Me Canuacmrs
Liunae law.
❑1 am exempt under Sec. .B&P C for this teasers.
r Date
WORKERS CO SATION DECLARATION
I hem y affirm under penalty of perjury mum of Me following demarsuans:
❑I have and will maintain a CertIRCam of consent to sel6imsum for Workers Compere
ration,a provided for by section 3700 of the Labor Cade,for Me performmce of six
work for which this permit is issued.
❑1 have and will maintain WMICeA Compenauon I.,as tequimd by Section
3700 of tint Labor Code,for Om performance or Me wart forwhlch this permit,s Issued.
My Worker.Compensation Insurance Cartier and Policy number am:
Cartier: Policy No'
CERTIFICATE OF E%EMPrION FROM WORKERS'
COMPENSATION INSURANCE
(This sectltm need notMcompleted if the permit 1s formic hundred dollars($100)
or lees)
I certify that In the perfomtance of Ole work for which MB permit is Issued.I shall not
employ any person in any Manor an h"fly m to Wmrkers'COmpensation
Laws ofC Ilona.Dw
ApphCans QQu�aa,�.... T. -' "� '
NOTICE . FUCANT:IL after a 'ng to CenlOcam of Exemption,you should
become sub Clio the Workm's Compentation provisions of to LaWT CMG.you must
.,O foMwM comply with such provisions or this permit shall M domed revoked.
,zt uj CONSTRUCTION LENDING AGENCY
)—i T hereby affirm the,them H a Mcm inn lending agency,for Me perrmimano or
!Yi ,5 M,wurk for which this permit Is issued(Sec.309].ON C.)
W Q UndoesNam-
z Lenders Addm•-
O Q 1 cenlfy that I have reed this application and ham Mat Me shove hromtat et us
UL correct.1a&=m comply wuh all city and county.Ninantta and sum laws relatingm
0 U building Construction.and hereby autmine represmistnes of this city to enter upon the
r[d1 above-mentioned property for Inspection Md OML
(We)agree to save,indemnify and keep harmless Me City of Cupertino against
,n ltabilitio,jadgmaoks,costs andexpemes which may in any way acemcagsinss tail City
U in eomx FsMCC of MC&M.Ming Of this permiL V. l�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2
SOU CE REGULATIONS. _
—� Z-t0't1iiC Re-roofs 0 0)irr.
Signs of Applmatoctintncmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant Bore or handle hundous material
as defined by the Cupertino Municipal Code.Chapter 9,11,and the Health and Safety
Codc.Section 25532(0° All roofs shall be inspected prior to any roofing material being installed.
❑Ya ❑N.
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
emit Wardous tar contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yia ONO
I have mail the haoaNnuamaterlals requirements under Chapmr6.95 ofthe Califor.
nice Health&Safcty Code,Sotions25507,25533 and 25534.1 undcraund thatif Mc Wilding
dos not currently have a senanl,that it is my responsibility m notify the occupant of the
requirements swhichmust w me a uisaykpOc,pl�a CcniOcem of Dec. cy.O-OE, Signature of Applicant Date
�r or out' h red event rh o2Cm All roof coverings to be Class"B"or better
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