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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