07030113 CITY OF CUPERTINO
gUILDING`DIVISION PERMIT Ct11T �C �1RIk`( IiM�Z'I(I1�1.
BUIL DRESS: PERMIT NO.
� � KIRWIN LA MBROWN CONSTRUCTION, INC 07030113
OWNER'S NAME: PERMIT ISSUE DATE
NOMA MICHAEL AND LYNN 702 S. DANIEL WAY 7
)NE:
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
ADD SK`rLIGHT IN LIVING ROOM BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
U FI hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z U with Section 7000)of Division 3 of the Business and Professions Code,and my license is
a a infull fff
arce and ee
j z License Class / Lic.I Q _
F-p Datc Conuaclor -
w ARCHITECTS DECLARATION
fit;av0„
i x a 1 understand my plans shall be used as public records
)yU
U. Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby alTirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Cale:Any city or county
<m which requires a permit to construct,alter,improve,demolish,or repair any structure
'2} prior to its issuance.also requires the applicant for such permit to file a signed statement
r< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation
C[- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law dos not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑f am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Com_�ns�a/tion Insurance carrier and Policy number are: /
Carrier. X71,L Policy No.:.:; d� 7/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z"" CONSTRUCTION LENDING AGENCY
(-+►CA-, 1 hereby affirm that there is a construction lending agency for the performance of
(Y> the work for which this permit is issued(Sec.3097,Civ.C.)
WGA. A Lender's Name
= z Lender's Address
U 0 I certify that I have read this application and state that the above information is
(y r- cored I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorize representatives or this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date J
SOURCEREGUL NS.
- ' --�" -3 a 7 Re-roofs
Signature of Applicturtirontrwtor Date
HAZARDOUS MATERIALS DISCLOSURE Type of R sof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs:;hall be inspected prior to any roofing material being installed.
C]Yes
If a roof i:;installed without first obtaining an inspection,I agree to remove
Will the applicant or forum building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m iterials for inspection.
District?
❑Yes m>
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which rior to issuance of a Certificate of Occupancy. Signature of Applicant Date
`s -7 All roof coverings to be Class "B"or better
Owner or authorized agent Date
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
'CPN# Date:
Building Address: Mailing Address (if different from building address):
$ r �.�.�
Owner's Name: Phone#:
Contractor: License#:
Contact: Phone: WF- t,to Cupertino Business License#:
�' " w d...� Fax: y-%Jv--Q
Building Permit Info: //,v�,�� r W.0rN—
Bldg P' Elect ❑ P umb ❑ Mech ❑
Job Description:
Residential, iw rvvJAI^- Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group:
aa. as TZ--3
Type of Construction: Please check this box if the project is a
A �I ` X1.1 - second-story addition: El
Project Size.- Stari Large-❑ .: --- e A,_.. - . r,.., ..
Quantity Fee ID �— Fee Description Fee Group
BAPPLOTHER Other Appliances ME HANICAL
BBOILERI Boiler<= 100,000 Btu ME ANICAL
BBOILER2 Boiler> 1 OOK to 500K Btu MECHANICAL
BBOILER3 Boile-> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Incl Off/Comm/Quasi BUILDING
BCONSTAXBQ Con Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC 1000 Elec 600V<= I OOOA ELECTRICAL
BELEC1001 Elf c 600V > IOOOA ELECTRICAL
BELEC200 Elec '►vcs 600V<= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk:: Lot:
APN . . . . . . . . : 3521006 . 00
DATE ISSUED. . . . . . . : 03y15/2007
RECEIPT #. . . . . . . . . BSC00000691
REFERENCE ID # . . . : 07( 30113
SITE ADDRESS . . . . . : 7579 KIRWIN LA
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : NOIA MICHAEL AND LYNN
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4338
RECEIVED FROM . . . . : REC'EIPT INTERFACE
CONTRACTOR CHF'IS BROWN LIC # 25108
COMPANY MBLOWN CONSTRUCTION, INC
ADDRESS 702 S. DANIEL WAY
CITY/STATE/ZIP . . . : SAN JOSE, CA 95128
TELEPHONE . . . . . . . . : (408) 260-1260
FEE ID UNIT QUANTITY IMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- ------ ---------- ---------- ----------
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 . 86 0.00
BPERMFEE VALUATION 2, 500.00 83 .16 0.00 83 .16 0. 00
BSEISMICRE VALUATION 2, 500.00 0.50 0 .00 0.50 0.00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 118.52 0 .00 118 .52 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 118.52 AMEX
---------------
TOTAL RECEIPT 118.52