05090181 CITY OF CUPERTINO *"� G`^'?•%+ '�" - "` ' ' - t "
BUILDING DIVISION PERMIT "CONTRACTOR'INFORMATION wz;
BUILDING ADDRESS: PERMIT N0.05090181
22032 ACACTA WAY
0 NE R'S NAME: PERMIT ISSUE DAM
JUSTIN MOZART Q2 /10/2Q06
E: SANITARY NO. CONTROL NO.
ARCHOECTIENGINEER: BUILDING PERMIT INFO
BLDG O ELECT PLUMB
30`O
LICENSED CONTRACTORS DECLARATION Job Description
1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing
z with Section 1000)afDiviabn 3 of He Business and Professions Code.and my license is
in fun fame and effect. SFDWL-2 STORY 2436 ' GARAGE 420 '
se
Licen Class Lic.of
Dam Contractor
ARCH IECI'S DECLARATION
6i I understand my plane ahall he used an public accords
py01
5 tad Loaned Professional
OWNER-BUILDER DECLARATION
!!11 I hereby a1Rrm that 1 am exempt from the Contractors License law for the
13 following mamin.(Section 1031.5,Business and lineations Code:Any city or county
$ which acquires a paten to eonsuuc.offer,improve.Occe-H h,m repair any suttetum $545885
y prior H its Issuance,also acquires thaapplicam for such permit to file a signed atatemem
that he is licensed pursuant to the provisions of the Contractor's Lana Law(Chapter9 Sq.Ft.Floor Area Valuation
y (commencing with Section 7 000)of Division 3 of the Business and Pofessinne Code)at
$ that he Is exempt therefrom and the basis fa the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil Penally of I ,y APP IAVMKer U U Occupancy Type
not more than Ras hundred dollars(0500).
❑1,u owner aides property,or my employees with wiles u their mile compensation,
will do dm work.and the awnus,Isom behind molfered forrau(Sm.1044.ausineaa - Required Inspections
and Profesdtma code:The Contracture License law doer not apply u an owner of q P
property who bullm m improves Hereon,and who does ouch work himself or through has
ownemployces,provided that such Improvements sm not intended OrOBered fntaim If,
however,the building or Improvement is sold within orc year of Completion.He Owner-
builder will have the burden of proving that he did not build or improve(or purpose of
.I.J.
O 1, a ni ner of the property,am exclusively contracting with licensed camOclors to
construct the project(Sec.7044.Business and Professions Cade:)The CmmcmrS Li-
cense law does not apply to an owner of property wait builds or improves thcmon,and,
who contracts for such inxi with a contractor(s)Incensed pursuant in the Crinoline
License Law.
Clem empt undo See BAPCfurthis.
r '�L--1 D.m Z LO -ob
WORKER'S COMP ATION DECLARATION
t hem affirm under pcnally of ury arc of the following dolsn0ons:
0 1 ban and will mammon a CenNcamof Cement in self-insure for WoM1Crs Compete
satian,on provided for by Section 3700 of the labor Cade,fm the performance of the
work for which this permit is issued.
0 1 have and will imm uin Workers Compensation Insurance.u requined by Section
3700 of the labor Code.far the performance of the work forwhich this Permit is issued
My workers Compensation h surame curio and Policy number are:
Career Policy Nn'
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need trot mcunplemd if de permit isfororc hundraddollm($100)
or Ir u)
1 certify that in the Performance of the work for which this permit is land,I mall not
cmployan penoninany manner uolii; ;te01*the WorkenteampemNan
Lowe of fomia.Dam
Applicant
NOTICE PPLIC'ANf:'If.after uria of Exemption.you Amid
become sub to the Workers Compensation pruvluom of the labor Code,you mica
.,Z forthwith Comply with such provisions or this parrot Hill be dcemW nevokcd
r y CONSTRUCTION LENDING AGENCY
[�w IMrchy eRrm that Here is a construction lending agency for the performance of
Cd> He work fm which this permit le issued(Sec.3897,C)v.C.)
W Q Lendces Nam^
z Lender's Addre••
U 1 cenlfy that 1 have read this application and stem that the above Information is
W;•" correct I agmo to comply with all city and county ordinames and safe law misting to
p SV' buildinteammcuon,and hereby authorise mimmenutivcr ofthis city to chum upon the
W abovo-mrnuuned property for impection purposes.
(We)agree to eve.Indemnify and keep harmless the City of CvWnino against
in liabilities.judgments,came and expenses which may in any my arose sow said City
UI.comequemeo fan treating of this permit. 2-�U-aor
n„ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS —a
" lw Re-roofs
Sig rc of ApplicendCOntracu -Z- a
Dow Of Roof
HAZARDO fATERIALS DISCLOSURE Typo
WIII the applicant or fume building uccupontsmrc m handle humorous mamrid
u deBmd by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safely
secuon 15531(a)7 All roofs shall be inspected prior to any roofing material being installed.
DYes ON.
Will the applicant or future budding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haumons air contaminants as dcftrcd by the Bay Area Air Quality Management all new materials for inspection.
DiWaict7
0 Yes ON.
I have read the hmmnus materials requirements undcrChapter 6.95 of the Califon
nia fiction a SafetyCode.Sectiom 35305,35533 and 15534.1 understand Hu lithe building
does wt cumndy ham a tenant.that it 6 my responsibility he notify On a:cupant Of the
acquirements which mum be me prior mmuwc.f,Certificamaf Occujumyb6 Signature of Applicant Date
e^4 - Z (Uf All roof coverings to be Class"B"or better
0 r u awhamod agent \ Date
C_