05090178 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON.'TRA.CTORANFO ' AnON:+ ,
BUILDING ADDRESS: " ' PERMIT NO.D S 0 9 017 8
10982 AQA(TA WAY
NER'S NAME: PERMIT ISSUE DATE
JUSTIN MOZART sANlrnav r.02/10/2006
N
2 /10/2COOr6ROL NO.
NE:
ARCHrMCrfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
3 o p LICENSED CONTRACTOR'S DECLARATION
1 hcnby affirm that I on licensed under provisions of Chopmr 9(commencing Job Description
with Section]ax)of Dlvielon 3 of the Business and Professions Code,end my license is
n� im full mneandeffect. SFDWL-2 STORY 1, 994 ' /GARAGE 433 '
5�Z License Clans Lle.g
7H Dale Comixcwr
ARCHITECTS DECLARATION
1 uMenta rl my plans shall ho used as public me.,&
J U
eaI Licensed Pro(cssionat
3 OWNER-BUILDER in co DECLARATION
Coo hereby
.. .nom that 1 1. uempt from de Cmmus Co Liscroc
Any c Law for my
eCoo following ressan (Section]construct,Business end ova.de ons Code:Any city or county
tg- which reyuina•jermn re cos the elver,improve,demolish,or repair signed munbm $451866
yjy prior he is licensed pursuant requites pis Aisions mfar mchpermitmimme Law(Chapter�< dm be is scConsed pursuant mthc of Division of the Ca Urines'alJcensess Code)or
Sq.Ft.Floor Area Valuation
}E B (cat he is exempt therefrom 7 ad m basis 3 the al aged c send on.An Professions vi Code)of
g�� that Me V exempt therefrom end the bats fm dm alleged corruption.Any violation of
Section 7031.5 by any appticat for a permit Subjects the apPluat to a civil penalty Or 3APNNWr1iiiMF U Occupancy Type
not more than five hundred doll.n($500).
0 1.a Owner of the property,m my employees with wages as their sale compensation,
will do the wars.a ad theatruman is art intended Of offend for sale(Sec.7W.Business Required Inspections
end Pro(essiom Code:The Cmaromm's Lkmo Law does not apply m an owner of q P
propertywho builds orfmp rves thereon,endwho doessuchwank hbnselfor through his
own employees,provided Net such improvements art not intended proffered faraale.IL
however,the building or improvement is mid within one year of mmpledon,the owner-
builder will have the harden of proving that Im did rot build or Improm for purpose of
sale.).
0 1.a owner of the propeny,em emlnsively conponmg with licensed mnusnan or
corstmct the project(Sec.70U,Business and Profesuans Code:)The COOpsmnr's Li-
cense law doer not apply in an owner of properly,who Wilds or Improves thenon,end
who contracts for such projects with a eonpacsoa(s)licensed purmat a the Composites
License law.
❑1 am eaempt under Sec. B&P C for this mVm
0 er a� D.m
�I`l�'' WORKER'S COM SATiON DECLARATION
I h by of one under penury of perjury one of the following declarations:
0 1 have and will maintain a Cerdficomof Convent to self-inaun for Worker'sCompmt-
sation.M provided for by Scotian 37M of the labor Cade.for the performance of the
work for which this permit is Issued.
0 1 have ad will maintain Worker's Compensation Insurance,as requited by Section
3700 of the Labor Cade,for the performance of the work for which this permit is loped.
My Worker's Compensation Imunnce caner ad Policy number art:
Came,., Policy No.:
CERTIFICATE OF EXEMPf10N FROM WORKERS
COMPENSATION INSURANCE
Clhbsoetian reed wt be Completed iftie I<rank Is fmaa Numb ddollar(51010
or lea)
1 certify that In the performance of the work for which thts permit b Issued,I shall not
employ any person in my mancrm alv- "111F T16t to OlUrken'Compenudon
Laws0 fmnla.DS'^
APPImium - —��
NOTICE PpucANT:IL after m n Il'ti rte of Escmpdon.you should
WCmme mail t to the Worker's Compcna on provisions of the Lahm Code.you Most
.JO forthwith comply with such provisions m Nn permit shall W deemed mvnkcd.
z CA CONSTRUCTION LENDING AGENCY
E" I hereby alarm that them is a cooslmcuon lending agency lot the performance of
:9 7 the work for which this permit is issued(Sec.3097.Civ.C.)
W Q Landers Nam-
z Lender's Addn^
U 0 1 cenify that I ham tad this applm uon and ram that the shove infmmnmm u
Ig, cmrecL I agree an comply with all city and county on inaces and cep laws relating to
0 U Wilding construction,ad hereby Suthonm representatives of this city to enter upon the
W .hove-memioned propeny for inspection purposes.
(We)agree to save.indemnify ad keep harmless the City of Cupcnino PiOR
liabilities,judgments.cusp ad cupenses which may in ay way mcrve Against Said City
U Z in consegpence of the granting of this permit
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. _
2' lD Re-roofs Q
Sig t roof ApplicapCOnuaceir Dam
HAZARDOUS MATE LS DISCLOSURE Type of Roof
Will the applicant err future Wilding occupal slow or handle hauns do material
a defined by the Cupertino Municipal Code,Chapter 9.17,and the Health ad Safety
•Sean.75537(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes DNu
Will the applicant or(uwre building oceupmn use equipment or devim`which If a roof is installed without first obtaining an inspection,I agree to remove
cosh ho puma,air cnnumi...Is u defined by the Bay Area Air Quality Management all new materials for inspection.
District
0Yes 0 N
I have red the haxam nmmamnalsrcquinmcau underCMpmr695 of the Califor-
nia 1ks lth&SafctyCade,Smdmu75505.75533p n5M ladcnund thulfdte Wddmg
does Out currently ham A moat,that it is my raponsihilty to apply the oceupat Of the
vimmcnot with tan be ern br Iicamof^cupiyy, yJ_ Signature of Applicant Date
Ost crorauthoorzdagcnt /• Dam L'o All roof coverings to be Class"B"or better
c