05090229 CITY OF CUPERTINOR
BUILDING DIVISION PERMIT ,CONTRACTnR+INFQM 'ATION
R
BUILDING ADDRESS: PERMIT NO.O 55 0 9 0 2 2 9
22422 CARNOUSTIE CT
ER'S NAME: PERMIT ISSUE DATE
JOHN & JUDY BRUZUS 09/30/2005
E: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
UOp LICENSED CONTRACTOR'S DECLARATION
to❑ 1 hemby affirm that 1 am 1'ransrd under provisions of Chapter 9(commencing Job Description
ZW with Section7")of Division3ofthc Busincesand Profeuium CWe.andmylicen=is
mmurame,ndercee 7�8�� 3 REVISION--ENLARG 2ND BATH/MOVING
j z Licen CI s Lie.a
Dam - - cantnna�n P77L3 �!t S% NO STRUCTURAL WALL
ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. #05060220
ay¢ 1undcrsund my plans shall b,used TSmpublic TION
7yU
g o Licensed Professorial ,
` 5 OWNER-BUILDER DECLARATION
<S I hereby affirm Nal I am exempt from Ne Contractors License Law for the
o O following mason.(Section 11131.5,Business and Porecs anal Code:Any city or county
t m which mgoirm a petml(m construct,elm,,improve,demolish,Or repair any sui nom
prior to ire issuance.also requires the applicant for such Permit o rile a signed snmmen(
<
that Im is licensed pursuant to the Provisions of the Cmunmial's U,Umc Law(Chapter 9 Sq.Ft. Floor Area Valuation
,H= (commencing with Section 7000)of Division 3o(theBusinessand ProfusionsCode)or $0
y _
that he is exempt therefrom and the buts far Ice alleged exemption.Any violation of
Section 9031.5 by any applicant for a permit subjects lite applicant to a civil penalty of APN Number Occupancy Type
ant ream Nan five hundred dollars(5500). .
❑I,as"net of the property,or my employees with wage as their able compensation,
will do the work,and the slsuctum is not intended orof and for sale(Sec.7044,Business
and Professions Code:no Contractors Licenu Law does not apply to an owner of Required Inspections
property who builds orimprnves themon,and whodoes suchwak himself or through his
Own employ=,provided that such improvements ere not intended oroRerod for sale.If,
however,the building or improvement is sold within ane yeti of completion,the owner- '
builder will have the burden of proving that Im did not Wild an improve for purpose of
sale.).
❑1.as Owref of the proPcrty,am exclusively contracting with licensed commucmrs to `�
construct de project(Sec.7044.Business and Prefessiom Cade:)The Contractor's Li- 0
elms law dura not apply to an owner of propony who builds or improves thereon,and g—
who contracts for such projects with a comnetor(s)licensed pursuant o the Contractors 9
License law. / '\
I sm exempt under Sea. B&P C for Nis moon V
Dam 7
WORKER S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations: Cv`
1 he ve and will maintain a Cenificatc of Cerium to elf-insum for Workers Comped- �l
cation,as provided for by Section 3700 of the labor Coda,for the performance of be
work for whim this permit is isaoed.
0 I have and will maintain Worker&COmpemalion ImurNR,as tequlmd by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation In senna artier and Policy number art:
Cartier: Policy No.: _
CERTIF An OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
C nu section used not Wcomplcicd if the Permit is for one hundred dollars(SIM)
or less.)
1 certify that in the performance of the work for which this permit u issued,l shall not
employ any person in any manner an as to become subject o the Workers'Compensation
Laws of California.Dam
Applied.(
NOTICE TO APPLICANT:IL after making this Cenifiute of Exemption,you should
became Subject to the Wohera Compensation provisions of the Li lmr Cade,you must
.JO forthwith comply with such provisions or this permit shall be accred mvoked.
Z' CONSTRUCTION LENDING AGENCY
[� I hereby am
affirm that them is a eovuctirm lending agency I.,the performuree of
CYthe work for which this permit is issued(Sec.3W7,Civ.C.)
WW Q Lenders Name
D E Lender's Address
U Q 1 certify that I have read this application and We that the above information is
com,cL 1 agree to comply with all city and county ordinances and sat¢laws relating to
OU Wilding construction.and hereby authoris repreaenutiKS ofthis city to enter upon the
T' W aluve-mentioned property for impection purposes.
(We)agree to save,indemnify and keep harmless he City of Cupertino against
fa/1 Iiabdider,judgmenu,class and cxpcnsm which may in any way accrue against said City
U Z I.ro.uquene.of the granting alibis permit.
SOPLI A YGULATIRS NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
NX
_45 9 Re-roofs
SWEstur OfAplp4icadVComUxmuur
HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will de applicant or future building occupant store of handle huardous material
as de0ved byWe Cupertino Municipal Cade.Chapter 9.13.and be Health and Safety
de,Semon 25532(x)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future Wilding Occupant uucquipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
r(hOrardnus air aonumimnts as defend by the Be,Alex Air Quality Managemem all new materials for inspection.
District?
❑Yes
I have mad the h t a dour materials mquirementa under Chapter 6.95 Olin,Califor
his Health&Safety Cade,Seedom 25505.25533 and 25534.1 undenund tha(ifthe building
does hill ham.ton that it is my responsibility m notify he==Pam of the
he rte ichmom elpriminismane,ofaea9fcateor apao,r. Signature of Applicant Date
umermiunharn,dagefit Dam
All roof coverings to be Class "B"or better