04110129 CITY OF CUPERTINO
BUILDING DIVISION PERMIT nCON'TRA.CTOI2INk'URMA IO1V X'
Bu1LDINGADDRESS: TU NGUYEN PEaMr /4110129
y OWNER'S NAME: PERMIT ISSUE DATE
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ONE: SANITARY NO. CONTROL NO.
CHITECDENGINEER: BUILDING PERMIT INFO
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BLDG
l� t� PLUM MECH
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+fop LICENSED CONTRACTOR'S DECLARATION lis Description
1 Worry aHlnn that I am licenand under provisions:of Chapter 9 onmmo
cromil
with Section 7000)ofOivision 3 of de Businwud Profmtiom Coda and my Iieenu B
cs in full forte end effect.
S�Z Loan m au Lk.g 6715'47 ADD 728 SQ. FT. FOR MS . SUITE/
Dam ?.9��commm �LA� RELOCATE
ARCHITECTS DECLARATION KITCHEN/FAMILY/DINING RM
I understand my plus shall le hand as public records
G�,S
Licensed Forestal...I
3 OWNER-BUILDER DECLARATION _
iy I kmhy affirm that I am exempt from his Contractors License Law for He
p o following moon.(Section 7031.5.Business and Aofestium Calc:My city or county
$lv which mqulrea•permit to cone alms Improve,demolish.or repair my s m ure
t-�Lh prior In its issuance,also requires the applicant for such permit m Bk a signed statement
�<
that hei.licensed perwant m true proviaiom of the Cannot luxnan Law(Chapter 9 Sq.Ft. Floor Area Valuation
D (commencing with Schon 70M)or Division 3 of the Business send Profcsions Cndc)or
3 Nat be a exempt theeRom and the basis for the alleged exemption.Any violation of $150000
Section 7031.5 by any applicant for a permitstsubjelea He applicmt m a civil penalty of APN Number Occupancy Type
tet mom than five hundred dollars($500).
I,u mwr of the pmptt y m my employes wl0 sups u detr tele cmnpenudon,
willdothewok,mdtheawetumbnminundedmo@mdforsale(Sec.70M.BuYrcas b 9 16 0 3 4 0 0Required Inspections
and Professions Code:The Contractor's License Law dors not apply m in owner of q P
property who Wildsorimprowa thercon,andwho doessuchwMhimulf or Wough his
own
owemployees.Wilding
ing or i that tachenti mid wuammyearofcmded moRered fm ow It.
however.,the Wilding a improvement 4 cold a did
ons year of comove n.far the purpose
of
sale). will have the burden of proving dant k did not Wib m Improve fm purport of
talc.).
I,u owner of Uro properly,.B sin. ad connecting Cod:)The C ronhacmu m
hnstroct owner
r of o(Sec.7014,Busloeu and Protracting Code:)The Comractm'a Lb
Tree Law dons nm apply to an owner of property who Wilda car improwa Hereon,and
who contracts for such pmkcu with a contracmKU licensed pursuant to He Comraonhra
LITme Law.
❑lamuemr/p�t(ru'nder Set ,B@PC fm this mason -
Owner Mizz Dau / 7N5
1371 Zi�ERS COMPBNSA71ON DECLARATION
I hereby off..under peraity of perb,oro hl the following declarations: -
Mm end will maintain TCW Omte ofConanm m anlf-imam fm Whrkert Compete
n,u provided for by Section 3700 of the Labor Code,fm the performance of the
I
for which this permit is issued.
have and will maintain Worker's Compersatian Insorum,u mquimd by Section
of Ne Labor Code,for the performance of the work fm which Nig permit is issued.
Worker's Compensation Insurance arti�errapndPolicy number artlerS'fA7E Co"VSfTLS q' cyNo.: (6'$�(a77sij R4,,�7'IFICATE OF EKEMP ION FROM WORKERS'
g•g/v4D COMPENSATION INSURANCE
(This ancdm bond not becompleted if the permit Vernon hundred across(SIM)
or beau)
I=rely Hot in the performance of He work for which this permit is issued.l that not
employ any person in my manpgls%umbecom ject mNe Workers'Compensation
Law.of Calif�[r!ia,D u �'JJ
Applicant /y�N
NOTICE TO APPLICANT:If,afer making this Ccnificam of Exemption,you should
become subject he the Worker's Compensation provisions of Ne Labor Code,you mot
.,Q forthwith comply with such provisions or this permit shall be demand aneroid.
r CONSTRUCTION LENDING AGENCY
EIhemby affirm that Nem is a construction lending agency for an
He performance of
> Em work for which this permit is issued(Sea 3097,Civ,C.)
G�5 Landers Name
.7. z Landers Address
U O 1 rmtily Nu 1 have mad Ila application and sum that We show Interaction is
ly Pcorrect.l agme m comply with all city and county ordinances and tete laws elating m
0 U building construction,and hereby mNorim representatives of this city m enter upon the
W .hove-mentioned properly for inspection purposes.
(We)as=to taw,indemnify and keep harmless trte City of Cupertino against
to) lobilitiesjudgments,casts and expenses which may in my way came againmatid City
U 7 In consequence of Ne starling of His permit. ,
C+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER ULATIONS
0 -3.14-20cy- Re-roofs
Signature of AppIi , Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant atom or handle husrdous material
CM,
ZdIlby tk Cupertino Municipal Coo.Chapter 9.13.and the Health and Salley
cod cy.3 us3z(a>7 All roofs shall be inspected prior to any roofing material being installed.
�Ym ON.
Will the applicant or future building occupant uta equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
It torturous air contaminants u kflncd by due Bay Area Air Quality Management all new materials for inspection.
:Act?
Dyes 0 N
I have mW the variations materials requirements under Chapter S95 of are Califon- /Jg &
Iresna
Health&Safety Cade,Scdw25505.35533 and 35534.immctuand dm Irian building
s not currently have a moot,that It a my oupomibility m notify the meup rat of the
uimmcwhiehmuubemdpctortaisuaneeofaCWfma focenpaney. Signature ofAppl Date
•tg+.200
owner oraulum7 Data All roof coverings to be Class "B"or better