05110049 CITY OFCUPERTINO ett «� s', Fg^ k �'�"w 33'"
BUILDING DIVISION PERMIT ,CQ, T .A-C l',CZRT�'F,(,�tM/�
l
BUILDING ADDRESS: ' PERMITNO. 05.10049
7556 KIRWIN LN
OWNER'S NAME: PERMIT ISSUE DAIS
DEMICK & KARIE LAU 00
E: SANITARY NO. CONTROL NO.
ARCHrTECUFNGINEER: BLDG BUILDING PERMIT INFO EI.ECr PWMB ME!}5
Imo . t� o I�
iOG LICENSED CONTRACTORS DECLARATION Job Description
1� I bercby affum that 1 w IlcoveO ander Providaro of CNpter 9(commencing
with Sectstn 70W)of DlHdon]af the Buainev atM Professions Code,aM mylstenseis
in lull room SFDWL-2 STORY (2859.' LIVING)
Ig: Liana Clea Ix.dARAGE-477 '
ARCHIi F p Da1C TS DIEmr
7th ms"I W min DELLA ON
I undenund my Plw alWl be used as public recorN
e c� Licensed Professional
5 OWNER-BUILDER DECLARATION
1 Monty affirm Choi i am ewyt mfrom the Contractors License Law fat ftO O following mason.(Sector 7131.5,Busincas and Profesainas Code:My City«county
$ which Motion a Permit an coronet,alter,improve,demolish.or repair any structure
iy prior to its issuance.all acquires the appliaot foraach permit m file a signed statement
2 < thatheisliamcdpuritanism0.provisimuofthcContractor'sLicenselaw(Charter9 Sq.Ft.Floor Area Valuation
2 g (eommeving with Section 7000)of Division]car the Business and Profession,Cade)or $639776
e that he Is exempt therefrom and the basis for On alleged emmptimv Any violation of
Section 7071.5 by soy applicant f«a permit obJccu the applleW m a civil Penalty Of APN Number Occupancy Type
not mart than five bundrad dollars(5300).
0 1,as amor of tie property,or my wployces with wages at Weir We eompewdon,
will do the work and the auucmre isnot Intended mortared for mki(Sec.7044,Banns Required Inspections
and Prefesdans Codc The Contractors License Law dee,rot apply m an want of q P
propenywho builds or improveathumal and whodoessuch work himeeUar through his
own employees,provided temoch improvements ere not intended aranered for vele.If. '
however,the building or improvement in sold within one year of completion,the Owner-
builder will have We burden of proving Was k did not build or Improve for Impose of
ate.).
0 1,u awner of did propony,am exclusively commuting with licensed contrwmrs in
common the project(Sec.7044.Budin¢and Profusions Cade)rhe Contractors LI-
cove law does an,apply in an Owner of proper who builds or Improves Norton,and.
who contracts for such projects with aconmcter(s)licensed pursuant to the Curtailments
License Law.
0 l am exempt under See .B A P C for this mown
Owns, Dam
WORKERS COMPENSATION DECLkRATION
I bermy same under penalty of Perjury arc of tic following declaradanc
1 haw and will maintain a CeNfiaate of Covent 10 self-ivac for WarkeraCatnpen-
nation.u provided far by Section 7700 of the Labor Caal for the performance Of We
wort far which dos factotum intrad.
0 1 have and will maintain Workers Compensation incomes,as Muimd by Section
3700 of the Labor Caal far the ped«matxe of the wort an which this penmts la las«d.
My Workers contami attoo Wurance eerier and Policy number
Carrier—�7/Ti)✓ �.a�J•Y� -4-1k7 No.:/-S�IJ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
a
This seNan mod mulccomum difthe permit is two=hundred dollars(SIM)
or[am)
1 anify,that in We performance of the work for which this permis is Wood,I Nall not
employ anyperwn in soy mannerw u to become object to the WOroW Campensadon
Larva of California.Data
Applicant
NOTICE TO APPLICANT:IL net making this Contrast of Exemption,you should
become subject in the Worker,Compensation provisions,of the labor Code you stun
OZ forthwith comply with such proviamut.or this permit shot]be deemed acvaked.
z CONSTRUCTION LENDING AGENCY
F-t I herehy affirm that them b•cor muctinn lending agency for the parommsuc of
Is the work for which WW permit Is luted(Sec.3097,Civ,C.)
WD Q Lenders Name
D 2 lander,acetest
U 0 1 certify that I have mad this application end state that the above Information is
0, correct.l agree to comply with all city and county ordinances and amm laws relating in
0 building constuction,and hereby audomi representatives 01`04 city to enter upon We
[T7 above-mentiotmd property for inspection purposes.
(We)agree to save,indemnify and kap hamtlesa We City of Cupertino agaWt
r fad limilities,Judgments.crots and expenses which may In anywy a«me agalvtastd City
U Z in APPLICANTeof the Standing of UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE Ns.
am
S cy 6 Re-roofs
Signature car App nmDate
US MATERIALS DISCLOSURE Type Of Roof
Will the app «future building Occupant stab or handle hazardous matedal
an EeWted by the Cupertino Municipal Code.Chapter 9.12.and rte Health sod Safety
Cam.Sectionv57xa)7 �� // All roofs shall be inspected prior to any roofing material being installed.
Oyu p(ra
Will the applicant or future building accupant use equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Immolate; ont
air caminsnts a dcfimd the by Bay Amo Air Quo lily Marmcm
gcnt all new materials for inspection.
District?
Ova / u
1 have cowl the heurdouamucnais acquhcnc«sunder Chapter 6.95 ofthe Califor-
at,HcdthkSafely Code Secti«m 15505.35577 and 255]4.1 undermost one Voice bidding
don not curmnty have•tanane this It is my mapoosaility in notify,die ocoupwt or the
myvimmcnts which �Ttprkowdomaupccof.Cmuflcatte af�R 6 Signature of Applicant Date
«.uthar'mte All roof coverings to be Class"B"or better