06080062CITY OF CUPERTINO
BUILDING DIVISION PERNIIT
s:.,.
BUILDING ADDRESS:
PERMR-NO. 06080062
7630 KIRWIN LN
OWNER'
08/251/2006
PHONE:
SANITARY NO, CONTROL NO.
ARCHTTECi/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professiuns Code, and my license is
in full force and effect-
REVISION OF TRUSSES. AS DEFERRED SUBMITTAL
License Class Lk. a
Date contractor
ORIG PERMIT #05110059—NO NEW PERMIT
ARCHrrFcrS DECLARATION
1 understand my plans shall he used as public records
Licensed Prufessional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor`s License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to consuucl, alter, improve, demolish• or repair any structure
prior to its issuance, aisu requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors Luxnse Law (Chapter 9
Sq. Ft. Floor Area
Val Wi203 0 5 5
(commencing with Section 7000) of Division 3 of the Business and Professions CDde) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
qqppN Number
umbumb
Occu arc e
P y I 'p
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more man. rive hundred dollars (s5W).
3 5 9 2 2 . 0 0
O I, as owner of the property, or my employees with wag= as thew sole compensation,
Required Inspections
will do the work, and the structure is riot intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended mr 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-)_
❑ L as owner of the property, am exclusively conuacling with licensed contractors to
construct the pmjen (Sec. 7044, Business and Professions Code:) The Cona=r's L-
eone law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor (s) Geensed pursuant to the Contractor'sLicense
Law.
❑ I am exempt under Sec . B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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.
M 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 Compensation insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS''
COMPENSATION INSURANCE
-
rfhis section necd not be completed i! rbe permit is for one hundred dollars (S 100)
or Icss.)
I 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
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, C'rv. CJ
Lender's Namc
,
Lenders Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorise representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
habilitia,judgmens. costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPUCANfi UNDERSTAtiqS AND WILL COMPLY WITHALL No? -POINT
Issued by: Date
SOURCE/' iULATTONS '5Z1
MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building rscevpant store or handle haardous material
as damned by the Cupertino Municipal Code. Chapter 9.1Z and the Health and Safety
Code. Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
2<0
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use
p g pa equipment or devices which
emit hazardous air contaminants as Fined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes No
I have read the hazardous materiais requirernens under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that If the building
at It is my responsibility to notify the occupant of the
does not currently have azap"rlorlo
require mcn hich must issuance of a Ccr ificatc o Oeeup��
/,
Signature of Applicant Date
��,�r�a
All roof coverings to be Class "B" or better
owncn•oramt,