06040041 CITY OF CUPERTINO
BUILDING DIVISION PERMIT hCON:TRAT.C,RTNptM;A' Q,�l�t,.,
BUILDING ADDRESS: DONG NGUYEN FEaMIT NO.06040041
10540 CULBERTSON DR
OWNER'S NAME: PERMIT ISSUBOATE
is DONG NGUYEN
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
DJC
_U s BLDG J ELECT rPLUMB O
3 0 uceNseo coNrancroR's o uRAnoN lob Descri 'ontjg 11
ZF!� 1 bcreby M.that 1 am licensed under provisions of Chapter 9(mmroaaing
<E
with Suction 7010)of Division 3 of Best.and Proroasioaf Code.Wmy Ike.is
�< mPonf—andeffece HOUSE DEMOLITION ?ryn
Lice..Ca. Lk.a ��644X
Date contra tot
ARCHITECTS DECLARATION
1 I understand my plans Nail W used u public revrrN m
So Licensed Pralwaonal 1
OWNER-BUILDER DECLARATION
i
COC
I mosso .(Rete o n 1 am accept from Nc Contractors Licence Law far the
0 o following n:unn.(Sadao 703 1.5,Business and Prefde ons Code:My riry s county
S$ which rtquimu a issuance.wo to uires due alter,imPmw,demolish.t at repair soy munch,uendure $16000
Sys metpriorhe its ensedpabumy0 the dueApplicantof farsuch Contra Permit Bic enseLacdataemem
ga thefheislicencedPunuanuotheproviaiovoftheControcarYLkxnalaw(Chaprer9 Sq.Ft. Floor Area Valuation
e (morn using with Section 7000) Division 3 of the Business and Pretentious Code)or
$ dm W u eampl therefrom and site baa for the alleged exemption.My violation of
Section 7031.5 by any apph ant far a permit subjects the applicant on a civil Penally of 3 AN r U U Occupancy Type
not mort than But,but dmd dollars($500).
0 1,As,owner of the property.or my employees with wages As their sole compensation,
a PPrroeaskom c�The Comism,tCa Yanafa Lmmal as.fiened rat LkeNe La.dao not apply y th N"wr�"or q P
Required Inspections
propeny who builds or improve themen.and whodwasuchwarkbimselfar through his
ownemploycas,provided thalsueh improvements ae not intended ma0ered formle.IL
however,the building or imp owmem is sald within ons yea of complebon,the awnsn
Wilda wilt haw the burden of proving that le did not build or Improve for purpose of
sok.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
conslrocf Life Project(Sec.7044.Business and Professions Code:)Tfie ContracmrY Lb
cove law does not apply to an owner of property who Wilds or Improves thereon.and
who mnmcu for such projects with a conuapar(s)licensed Forecast m ds,Contractors
Lkense Law.
O ImummmptuncerSm .Bl PCfwmN aan
ms Dam
WORKER'S COMPENSATION DECLARATION
I hereby damn Mier penalty of pejury o e of me following dalaniaN:
7037'YOO.f
have and will maintain•CeNOae of Conant m sal umm far Workers Compete
E a provided for by Section 3700 of the Labor Code,for the performance of the
fa which this permit is bound.
haw and will maintain Workarf Compensation Woman,a required by Section
Ne Labor Code,far the performance ofthe work fa which this Permit iI I tWmkoes cheapers an Insmaee c d Policy m er. /g. ? Frit!A� Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This xNnn onetl not bo compleatl o de permit Is fa one hunthd dollars($10)
err leu)
1 cenify that in the performance of Lite wattle for which this Permit is issued.I Nail not
employ any person in any manners As an become subject to fie Workers'Compensation
Laws of CaiUomla.Data
APPIIam
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,yen should
become subject m the Workers Compensation provismas of the Labor Code,you muss
O O forthwith comply with such Parisians m Nu Permit Nail W darned semked.
'zn CONSTRUCTION LENDING AGENCY
[—i I lemby Warm saw chert is a consrmNnn lending agency for the performance of
a r7 the work fm which this permit is wood(Sec.3097,Civ.C.)
fenders Name ,
z lender's Address
U C 1 certify that 1 haw red this application and some that the show infmmNun u
{i.P carter I ag.to comply with all city and county andinaaef and sum lam relating to
0U building construction,and hereby audumire tepresemadva of this city to enar upenthe
W above-memimmd property for inspection purposes.
(We)agree to ave,indemnify and trm
leap hadea the City of Cupertino against
raja liabilities.fudgmana.coati and expenses which may In my my werem against aid City
U Z in covequmem of the grating of this permit /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date J i -6
SOURCE REGULATIONS. .
��. 6-13/&.6
sienaare cur ApplseatfGon r .e Re-roofs
X US MATERIALS DISCLOSURE Type of Roof
Will Lis,applicant or future building occupant wrc or handle hvsNov material
as defined by the Cupertino Muni Pal Cade.Chapter 9.13,and the Health And Safety
Section 3553x4)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or fufurt Wilding accupanf use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emir hoar mus air contaminants a defined by the Day Area Air Quality Management all new materials for inspection.
DiuricR
0Ya 01N.
I haw read the Natant.risedais requimmew undm Chapserb.95 oftis,Califor.
nia fkal"Safely Cade,Sections 25505,25533 and 25534.I understand that ifthe Wilding
dad cut eareroly haw a sae4 thin it Is my responsibility m Mdfy the acupaf of de
requirements which most Wmefprior towoman ofaCentrists:afOccupancy. Signature of Applicant Date
Owner or autharNed agent DateAll roof coverings to be Class "B"Or better