04080047 CITY OF CUPERTINO I•pi+ r ,77,7, q "-
BUILDING DIVISION PERMIT JCONTRACTOR3INFORMATION:4
BUILDING ADDRESS: PERMIT cb4080047
OWNER'S NAME: PERMIT ISSUE DATE
THANH PRUN
SANITARY NO. CONTROL NO.
ARCHITECCfENGINEER: BUILDING PERMIT INFO
BLDG EIPCT PLUMB MECH
(� 0
LOo LICENSED CONTRACTOR'S DECLARATION
W
Fq 1 Wreby arum that 1 am licensed under provisions Of Chapter 9(commencing Job Description
iW with Section7000)of Division 3 of the Business and Professions Code.and my license,is
^LJH InmBcClass force eff"` ADD 560 SQ. FT. (FAMI.LY RM/BEDRM)
j=z Lkcnw Class Lie.g
Zr' Dow Contnciel
ARCHITECTS DECLARATION
rc 1 understand my plans shall W used u public records
ile
C t�, Licensed Prosio
fesnal
3 OWNER-BUILDER DECLARATION
<E I hereby ol7rm Nat I am exempt from On Contractor's License Law for the
00 following m=.on.(Section 70313,Business and Professions Code:Any city or county
which myuires a pemrit m ennsuuct,alm9 improve,demolish,Or repair any structure
Fiy
Poor o is issuance,also mLumsthe applicant for such permit to file a signed statement
££s< that he is licensed pursuartrothcFmvlsinnsof0.Contractor's License Low chapter 9 Sq. Ft. Floor Area Valuation
yt-$ (commencing with Section 7000)of Division 3 of the Business and Pmressiaru Code)at
_ dont W is eacmpt therefrom and the basis for the alleged mo mptum.My violation of
Section 7031.5 by any applicant fora permit subjects On applicant tO a civil penalty of 37AP3nQUFw1et00 Occupancy T
not mom man five hundred doll..(M). P Y YPe
El I,n mw ofthe pmpemy,or my emplOyres with wage u thea wle compcnvdnn,
will elo Newark,and me suucure u notimended Oroffemtl for.Wc(Sa.]614,Budrress
and Profesnom Code:The Comersecmrs License law docs not apply or an owner of Required Inspections
propel who builds orimproves demon,and who doessuehwurk himwforthrough his
Own employees,pmvidcd that such improvements arc not intended oro@red forsake.If.
however,the Wilding or improament is sold within m¢year ofcompletion,the owner- p ppp r�
Wilder will base the burden of pmving that he did not Wild or improve far purpose of illi\���1�I l..f�
sale.). 14
I,m Owner of Ne rt am esclmivel contracting N licensed comraeors m if
co S c. YY 6 wi
construct Ne protea(Sec.7044,Business and Profcsvorts Cade:)The Convacmr's V
ense Law docs not apply in an owner Of property who Wilds or improves menton,and I Ing I
who contracts for such projects wit a conuacmr(s)licensed pursuant m the Consciences �T d
Licence law.
❑1 am cxcmp under sec. .B&P C for Nis reawn
Owner
Go ab o : , Fw ii�. P�
WORKER'S COMPE . ION DECLARATIOII s r t
1 hereby affirm under Penalty of perjury one of Ne,following daclarations:
I have and will maintain a Certificate ofConainuo sel6insum for Workers Com ed-
anion.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 Workers Compensation Insurance as mquined by Section
3700 of the Luber Code,for the pmfonnanee of the work far which this permit is issued.
My Workers Compensation Insurance comfier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the Permit is formic hundred dollars(SIM)
or basal
I cenifv Na in the performance of the work for which this Permit is issued,1 shall not
employany pawn in any mannefsp u3n be�Ocwbjcnm Workers Compensation
Laws of Cilifom'ty, Datg U!FIJf ��uC �1
Applicant o"
NOI'ICETO APPLICANT:It.afar making Nis Ccnlrcae of Esemption,you should
become subject to the Workers Compensation previsions of the Labor Code.you must
.,z foMwith comply with such provisions or Nis permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hemb afrrm Nat there is a em¢vuctinn Lending In the formm.of
F r ga.) r Ter
7. v� 1- work for which Nu permit is issued(Sec.7097,Civ.C.)
1 z Under's Name
,�z Lendees Address
U 0 I certify that 1 have read this application and shim that thc soon information is
[L.Pcorrect I agree to comply with all city and county ordinances and sum laws relating to
DU Wilding construction.and hereby author representatives or this city in enter upon Nc
}4i7 ahovc-mentioned property for inspection pmle n..
f~ 1 (We)agme or save,indemnity and keep harmless the City of Cupertino against
fA
Haitians,judgments,costs and expenses which may in any way accrue against mid City
U in comequcnce or the granting of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE GULATIDNS
.
10 Re-roofs
gnmumof Applicant/ onuacmr Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant store or handle hanrdous material
as darned by On Cupertino Municipal Code,Chapter 9,11,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected nor to an roofing material baso installed.
❑ret �pNm P P Y g g
Will he applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it horardous air con ominiums as defined by me Bay Area Air Quality Management all new materials for inspection.
District'
Vu
1 have reek the hnardous ntaerialsmquimments under Chapmr 6.95 of hm Califm-
nia Health&Safety Code,Sections 25505.15533 shot 2S53d.I undersand Nazif tbe Wilding
does nut cumendy bane.mnanL that it is my res,rul hility to Wory the occupant of Ne
mquimmc which must beret poor issuanceofaccrtificamof Occupancy ignature of Applicant
Date
42A "�'�giluitr or authorimd agent All roof coverings to be Class "B" or better
Dam g