15050139 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10685 LARRY WAY CONTRACTOR:DANG THUY THI XUAN PERMIT NO: 15050139
AND NGUYEN LONG
OWNER'S NAME: DANG THUY THI XUAN AND NGUYEN LONG 10685 LARRY WAY DATE ISSUED:05/22/2015
OWNER'S PHONE: 4085905295 CUPERTINO CA, 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION REVISE SCOPE OF WORK ON PERMIT 00040093 TO: SFD ADDITION(1643
SQ FT);REBUILD(E)SFD(1517 SQ FT);REMODEL GARAGE(440 SQ FT).
License Class Lie.# TOTAL NEW LIVING SPACE IS 3160 SQ FT.
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$0
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:31602009.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, / /�—�,� Date:
costs,and expenses which may accrue against said City in consequence of the �� tiJ /��/!� �J
granting of this permit. Additionally,the applicant understands and will comply Issued by:
with all non-point source regulations per the Cupertino Municipal Code,Section
918.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,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,
f
usiness&Professions Code)
as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
onstmct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupert' Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti s 2550 ,2 533,and 25534.
)ection 3700 of the Labor Code,for the performance of the work for which this s;-. <<' "s ..,E ' ter.,'�i,2Owne a �rmit is issued.ertify that in the performance of the work for which this permit is issued,I shall
f employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's 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 authorize 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 liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-poi source re ations per the Cupertino Municipal Code,Section Licensed Professional
9 18. xr j
igiature'
s -
15a5D1� �
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(Qcupertino.orq
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# C1
PROJECT ADDRESS n UJ
N APN#
OWNER NAMED �/ b �/ v�� PHO U D E GI/V /�
STREET ADDRESS - ,--j CITY, STATE,ZIP �i;._• gam. FAX
CONTACT NAME Gym PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK CAj ! �o � ^ (�,.�-� .�1 C)J)O A/I j � •7_ �O
'5 fD T\0 rA '�7 s F&C94 `IL�
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
V173 I USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO
/ vTOTAL
AREA J5! 7 AREA ( ,qAREA 6)_ NETAREA.
A/kD
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
Ivo 4ErATTACH
#DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY []YES
1 BEING ADDED? gNO ADDITION? RNO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED ": TOTAL VA TION:
PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER EICHLERHOME? VIVO
By my signature below,I certify to eachof the ollowing: I am the property owner or authorized agent to act on/the property owner's behalf. I have read this
application and the information I have provid is correct. I ve ead the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bui in construction an rize representatives of Cupertino to enter the above-Iden flieed. property for Inspection purposes.
Signature of Applicant/Agent: r y 1101-6
-« r ,' .- Date:
SUPPLEMENTAL INFORMATI N REQU Phnri GHEcx TAPE . " RoUzlNcsi Ip'"
New SFD or Multifamily dwellings: Apply or demolition permit for GVER I wTim COUNTER BInLDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑' ExPRESS" Ely:
'PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElRII ❑ PUBLIC WORxS
form if any Hazardous Materials are being used as part of this project.
El LARGE ❑"FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
Submittal Of Building Permit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT
❑"ENVIRONMENTAL HEALTH
B1dgApp_2011.doc revised 06/21/11