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CITY OF CUPERTINO'ibxa�>'
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BUILDING DIVISION PERMIT
CONTRACTORINFOI.LMATION 7
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BUILDING ADDRESS:
PERMIT N005090180
R'S NAME:
PERMIT ISSUE DATE -
,JUSTIN MOZART
02/10/2006
PHONE:
SANITARY N0, CONTROL NO.
ARCHITECT /ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
o
1 humby affirm that I an licensed under previsions of Chapter 9 (cummem ing
with Section 7010) of Division 3 of do Business and Professions Code, and my license is
I. full tore. and affect,
SFDWL -2 STORY 2436' GARAGE 420'
Llarsc Class Lic.0
Dots Conmamr
ARCHITECT'S DECLARATION
'
i understand my photo shall a used as public factors
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt farm the Contractor's License Law rot the
following mason. (Section 7031.5. Business and Propositions Code: Any city of county
which requires a Permit in conswct, alur. improve, demolish, or mpoir any nmcbre
$545885
prior in its issuance, also requires the applicant for such permit in file a signed suument
that he is licensed pursuant to the Provisions of to Comncbr'sUcemo Law (Couples 9
Sq. Ft. Floor Area
Valuation
fcommencing with Section 7000) of Division 3 of the Business and Prefireons Code) or
War be is exempt therefrom and the basis for the alleged exemption. Any violation of
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Occupancy Type
Section 7031.5 by any applicant for a pemdt subjects the applicant to a civil penalty of
not mofa than five hundred dollars ($SW).
❑ 1, m owner of the pmpeny, m my emphoycu with wages u their tole eomNmdon.
Required Inspections
will do the work and themmnue is am intended or offered rotate(Soc. 7041, Bum.
and Pmfeuiou Code: The Camrecbh Lt. Law due, set apply b an owner of
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property who builds or improves thereon, and who does such wort himself or through has
own cmploycu, provided thaisuch imp nvemenu are not intended reoffered (resale. IL
however, the building or improvement is said within one you of completion, the owner.
builder will have de louden of proving that he did not build or Imprmc for purpose of
talc.).
Q 1, as owner of the property am exclusively contracting with licensed contractor In
construct the project (Sec. 70". Business and Professions Code) The Contractors U.
tests, law arcs not apply in an owner of property who builds or Improves discount, and
who contracts for such projects with •conuacom(.) licensed pursuant w the Gonuamert
License Law.
❑lam ea pt under Sec. B k P C for this tenon
r Date
WORKER 'S COMPE ATION DECLARATION
1 hurt tm under penalty of perjury one of the following dodamdons:
❑ I haw and will maintain • Cenifinte of Consent bself -imurt for WorkereCampen-
ution, as provided for by Section 37W of the labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37M Of the lobo, Code, for the performance of the work for which this permit is issued.
My Workers Compensadon Inutance artier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need m atitcompleud If the Permit Is ftrone hundred dollam fil W)
Or loss.)
I unify that in the performance of the work for which this permit is immed. I shall not
employ any person in my mmncru the Workers Compensation
Laws of California. Date
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Applicant
it TO PUCANT: If, after fr this Cc me of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
rOMwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby strum that Bert is a comuuction lending agency for rte performance of
the work for which this permit is issrcd (Sec. 3097, Civ. C.)
Undoes Namc
,
Lender's Addrtu
I certify No 1 haw rtW this application and auto that the above Infomu0on Is
correct. I agree to comply with all city and county a r inances end cute laws relating in
building construction, and hereby authorm representatives of Nis city to cme upon the
ahove- mentionW propcny for inspection purposes
-
(We) agree in taw. indemnify and keep homeless; the City of Cupenum against
liabilities. judgments, cmu and expenses which may in toy way accom sgah un said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: Date ''2, �
SOURCE REGULATIONS.
Re -roofs
Type of Roof !v/
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signs fApplicanUComnctot Dow
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding oaupent nom or handle huardou material
defined by the Cuperdno Municipal Coda, Chapter 9.13, and the Health and Safety
c. Section 25532()?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONO
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment m, devices which
cult hazaNnus air cum uninants as Mined by des: Bay Area Air Quahity Management
all new materials for inspection.
District?
❑Ym [I No
I hove read the hamnlous materials requirements under Chapter 6.95 or the Califon
nia Health @ Safety Code, SectioM 255)5, 25533 and 25534,1 underatantd rho ifthe building
does not currently how a ensm, that it is my maptab biiity b and ry the occupant of the
.,I is which mutt h met prior wiuuanccora Certincau orOccuponcy.
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Signature Of Applicant Date
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All roof coverings to be Class "B" or better
Ow
rauthorizedagent Date