05110059CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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a:5.c3%
BUILDING ADDRESS:
PERMIT NO. 0 5110 0 5 9
7630 KIRWIN LN
R'S NAME:
PERMIT ISSUE DATE
02/10/2006
PHONE:
SANITARY NO. CONTROL NO.
ARCHTTEC (ENGINEER:
BURRING PERMIT INFO
BLDG PLO
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LICENSED CONTRACTORS DECLARATION
Job Description
P
1 lately afflon that 1 Am Ikemd under provisions of Chapter 9 (Commencing
with Section 7010)afDiWdon 3 of No Bug. and Professiaas Code. AM my license u
in full to= and effect.
ADD 1507' (582 I -1ST.. FL/925' -2ND FL.)
License Class Lk.0
Dam Commons
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NEW ROOF/NEW LIGHTS.
ARCHITECTS DECLARATION
1 udcnund my plan shall he used u public moods
Licensed Professmnal
OWNER -BUILDER DECLARATION
1 hereby a/Mn that I em exempt from NC Contncrort License Law for the
fallowing mason. (Section 703 1.5, Business and Profession Cnde: Any city or county
which mquirn a permit m construct, alcor, improve, dmmllah. m repair any suuctum
prior m its Women, alms requires the applicant far such permit to file A signed s memeni
Contractor's License law9
Sq. Ft. Floor Area
Val"DiS 055 .
Nat he is licensed pursuant to the provisions of Ne (Chapter
(commencing with Section 7000) of Division 3 of the Busbassand Profeasions Code) or
Nat he ts exempt therefrom AM Um basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Sedan 7031.5 by any applicant for a permit subjects the applicant m A Civil penally of
not mom than an hundred dollen ($500).
35922015.00
❑ L u owner of tie property, or my employe with wagesas Near mle compensation,
Required Inspections
9 P
will do the work,.nd Netwnure is notintended oro@red hernia (Sm. 70th, Bu4men
and Profesalons Code: The Consanott License Law does not apply m an Owner of
property who builtm improved Neuron.and whodatsuch work himselforduough his
own employees. provided that Such improvements art nmlmunale i monered for sale. B.
kwweer, the building or improvement is Sold within one year of Completion, to awnm.
builder will have the burden of proving that he did nut build or improve for purpose of
Sam J,
moi. As .1 of the Coupon, Am eminively conuaming with Rcensed contnnma m
Conwcl Ne prejen (Sue. 7014, Business aha Profession Cade:) The Conuxmrs LF
ane Law don nm apply to an owner of praperty,who hdids or improves thereon. and
who Contracts for web pmjema with a contractor(s) licensed pursuant no Can Convenors
License law.
❑lam uemplu xS e. .BiPC th'rtasCo
Dam 2- to 6
COMPENSATION DECLARATION
1 hereby aakm under penalty of perjury orc of the following dcelanllons
❑ I haw and will maintain a Cadnca cof Cmncmm self-inum for WatkeesCompen-
u pro fpe by Sada 3]00 of Ne Tabor Code. fm Bre peRosmance of the
work for which Nis pennh It issued.
wants f h this
❑ I have and will maintain Worlect's Competwilon lasunnce, u required by Suction
3700 of the Labor Code. for the performance of time work for which lhU permit is Issued.
My Worker's Compensation Insurance envier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bocanplemd ifthe permit ts forma hundtaddollan (1110))
or loss.)
'
I certify Not in Ne performance of the work for which this permit ts issued, I shall not
employany person i9�nyon ngLsclAS lNexmewbjectmthewmken'Compenu0on
Lawn of
after you Mould
ns Exemption,bo
NOTICE TO A ICAN1he
Wod r' Cause,
of tite labor Code, you mute
n p visi of the
Compensation
become subject to the Worker's Compeormkn
crovtsmn
forthwith comply with wch prevision or this permit shall be deemed revolted.
LENDING AGENCY
1 hereby AT. Net them Is ... romermonn lending agency for the performance of
the work fur which this permit It Issued (Sec. 3097, Civ. C.)
Name
lenders Address
I certify that I have red this appaieda aha tau our the tame information u
I Agra m comply with all city sad county ordiwwes and sum Ian mldng m
Wilding conwuctioo, and hereby interim cepreseuUcim of this city m enter upon Nc
alUvcmCMand property for Inpeelion purposes
(WC) agree m Ave. indemnify and keep harmless the City of C'upCnlmm against
liabilities. judgmenu. cru and expenses which may many way accrue against said City
in canegance of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WLLl COMPLY WITH ALL NOWPOINr
Issued by: Date
SOURCEEP:L(1 .A IONS.
T4 2-1151
Re -roofs
Type of Roof
Shicamme of pmcan✓Caumtor Doc
MATERIALS DISCLOSURE
HAZARDOUS
Will the applicant Or future building Occupant Mom or IMMIC hundou material
defined by the Cupertino Municipal Code. Chapmr 9.11. AM the Health and Safety
•. Second 25m$a)!
All roofs shall be inspected prior to any roofing material being installed.
❑Yes apes
If a roof IS Installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use cyulpmem or devices which
emh hanrdous air conmminanu as dc0ned by She Bay Area Air Quality Management
all new materials for inspection.
District!
❑Yes 01<0
I hive and the hurardnus materials requlmmenu under Chapur6.95 athe Califon.
nu Health@ Safety Coda, Section 15515,15533 sad 15534.1 undcrauM imlifNo building
Jan not currently haw A unnt, Nat it is my msponNlllty m notify the nocupanl of the
require
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