05090183 CITY OF CUPERTINO "
BUILDING DIVISION PERMIT aC`U.NTRA.C 'OR INP'O'RMATIUNa`
1BUILDING ADDRESS: PERMIT NO.0 5 0 9 018 3
10985 ACACIA WAY
0 NE IT R'S NAME. PERM ISSUE DATE
JUSTIN MOZART 02/10/2006
E: SANITARY NO, CONTROL NO.
ARCHITECTENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u p p LICENSED CONTRACTOR'S DECLARATION
I u I hereby affirm that i am licensed under provisions of Chapin 9(commencing
Job Description
with Section 7000)of DiviAon 3Of the Business and Professions Codc.and my license Is
im full force and effect. SFDWL-2 STORY 1944 ' /GARAGE 433 '
38? License Clue e.N
n F y Date Lmonemr
ARCHITECTS DECLARATION
1 undctstanA my plum shall be used u public records
J
h8 Licensed Professional
OWNER-BUILDER DECLARATION
' I I hereby.(Mere Nat 1 am
1. exempt from the cumns Co License Law for be
O o following round.Permian 703 1.5,m t,alrcst and improve.de oar Cade:Any city or county $451866
yB 0 which coquina a c.Also re enmVUCt alter,improve,do ermiti or repair any summer
-iy prior he isl issuaz4alaurequite We visocut for such Permit mfilea Law(tstemen
< tharW is licensed
wait PUruan0000)pmvWOm of lbe ConuacrosYlJanselaw(Clodter9 Sq. FL Floor Area Valuation
ze that he s exempt Section 700 0)of Ddwim r of the Business;exam and on.Any vi Cade)of
��.- that be u exmmpt tbertfrom and the basis f«tie alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of APlq I lIffi6'er tJ V Occupancy Type
not more than nve hundred dollars(55004
0 1.uowneroftheproperty mmyemploymwithv gmutheirsoleampenudon,
will do the work real dimurumute isnot inrendedoro @real ratude(So.7014.Busmw Required Inspections
and Pm(esalou Code:The Committees Liam Law dm not apply ta an Owner of q P
properly who bulidsorimpraves thereon,and who doessmh work himselforthmugh his
awn employm,provided that such improvements are notintanded u offered for mile.If,
however,the building or improvement Is mid whin am year of completion.Ute Owner.
builder will have the burden of proving that be did not Wild at improve for purpose of
sakj,
❑1,as Owner of de propeny,am exclusively contracting with licensed contractors u
construct the pmject(Sec.7014,Business and Profanons Code:)The Conuacmr's Li-
cense Law dm not apply to an owner of prapeny who Wilda or Impmvu thereon.lid
who contracts for such projects with a cammictor(s)licensed pursuant m the Contractors
License law.
❑1 am exempt under Sec. ` f B&P C far this mason
ter 1Vf'�}� Date
WORKER'S COMWNSATION DECLARATION
1 bertby affirm under penally of perjury arc of the following deelana oas:
❑I have end WIl maintain a CaAfcam of Comrm to elf-wort fa Workeet Comprn.
union.a provided far by Section 3700 of the labor Code.for the performance of the
weak for which this permit is arced.
❑1 have and will maintain Workers Compemaaon Wmuunce,as required by Section
1 3700 of the Labor Cade.for the performance of the work fm which this permit is Weed.
My Worker's Compensation Insurance carrier and Policy number use:
Carrier Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS
-. COMPENSATION INSURANCE
(This section need not he completed if the permit is Imam hundred dollars($100)
or Ica.)
1 certify that in the performance of the work far which this per it is Issuctl,I shall nut
employ any person in any manmrm u mJoampcua> rkcri COmpcuNan
Laws of Qpllfamla.D ' N_
Appilant - _ -
NOTICE I PLICANT:If,efts,Wong t Ce u of Exemption,you should
become subj to the Worker's Compensation provisions of the labs Code,you must
., O forthwith comply with such provisions or thus Permit shall be deemed revised.
Z y CONSTRUCTION LENDING AGENCY
(-d I maby affirm that Vert isaroutmctinn lending agency far the perfarmarxe u(
ai> the work for which this permit Is mad(Sec.3097,Civ.C.)
ILl0 Lenalce:Nam.
z, Lemike Addra
t.7 Q I unify that I have rail this appliatian and sum thus We Am.infamtaaw is
Iy carrel.I agree to comply with all city and county on inarNa and Rule laws mlatu{W
0 U building construction,and hereby authorize mpteunumed Of thus city to enter upon the
,ra above-mentioned property for impecuon purposes
(We)agree Ire lave,indemnity,and keep hmxIW3 the City of Cupertino against
o-F.t rA liabilities,judgments,costs and expenses which may in any way seem against raid City
fJ z to consequence of the granting of this permit /T
^� APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT�_ Issued by: Date L
SO RCE REGULATIONS. -'%_ (t, ^-' _
Re-roofs Q
Stpna of A,plkaAVC.nmMWr Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occuput atom of handle hamrdous material
u defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Section 35532()7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicant or future building Occupant use If a roof is installed without firs[obtaining an inspection,I agree to remove
{ e equipment at devise which
emir huvdnus air contaminants u defined by tbe Bay AMA Mr Duality Muapcmenl all new materials for inspection.
Di umR
❑Yee ❑Nee
1 have and the hararcus materials requirements under Chapter i95 of the Cali for-
nu Health @SafctyCO ,Secauu25505.25533.d2S534.IwWCrsuMdutifdc budding
Jas not currently have s tenant that it 4 my rupomibility W mufy the aceuput of de
virtmcnts whkIt muss be sect rmusauee fl Ccnifiae arOcapaomy. Signature of Applicant Dale
itcgoegaii
t e All roof coverings to be Class "B"or better
Ow or RUthonsd agcm Dale