06050192 CITY OF CUPERTINO s
BUILDING DIVISION PERMITCONTRACTOR INF, URMATION ,
BUILDING ADDRESS: M-IRAN CONSTRUCTION, INC PERMIT"°.06050192
19065 PENDERGAST AVE
OWNER'S NAME: PERMIT ISSUE DATE
MINH TRAN & MY-NGA DO 348 SURBER DR, 06/19/2006
Ea SANITARY NO. CONTROL NO.
(650) 996-6099
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
(�
�O o LICENSED CONTRACTORS DECLARATION
C 1 hereby affirm that 1 am 1"ucnud under provisions of Chap.,9(commencing lob Description
L� witA Secdan]O[IB)of Diyy'sion]of NC Busincv and Pra(ccsium Cpode.andmyli<enuu
±�„ infullforteandcf(tt11 REVISION TO ORIGINAL PERMIT #05020184
y�Z Lkenu Claz Y�I,}L([�(5V Lic.N zTf��sfvVk�
eFG ' ARCHITECTStDECLARATION REVISION TO TRUSS CALCULATION
�a< Iundmatand my plans shalt he used upahue recordsORIGINAL: SFDWL-2 STORY 3542 LIVING, GARAGE 44
JyU
III.
Umosed Professional
5 OWNER-BUILDER DECLARATION
iI hereby 211inn that 1 am exempt from the Conuanoes License Law for the
i c O fallowing mazon.(Section](B 1.5,Business and Professium Code:Any city or county
which acquires a permit to constmn,after,Improve.demolish,or repair any tvunum
—Z< prior in is iuvancc.also requires the applicant(orsuch permit to file a signed statement
that he is licensed pursuant mthe provisions ofthe Com one's License law(Clapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section]000)M Division J of the Businessand Professum Codc)or $O
a. Nat he is ezcmpt d em0om and the basis for the alleged exemption.Any violation or
Section]031.5 by M applicant for a Permit mbjccs the applicant to a civil penalty of ApN Number Occupancy Type
trot mom than(von hundred dollars($500).
❑I,as owner of the property.or my r+nployca with wall as tie'v to compensetimn,
will do the waste,and the munum is not landed or offered for sale(Sec.]Ma,Busimas
and Pmfrssime,Cods:The Convenor's License Law dol not apply m an owner of Required Inspections
property who builds or improves tbement.and who does such work himulforthrough his
own employees.provided tharsuch improvemmu are not intended aro@red ferule If.
however.Ne building or impmvemun is mid within oe year of completion,the owner-
builder will have the burden of proving that M did not Wild or improve for purpose of
sale.).
❑1,as owner of the property am exclusively contracting with Bearded cenuanea to
conswct the pmjen(Sec.]014.Business and Professions Code:)The Cmemmu is Li.
cense Law doer not apply m an owner of pmpenY who Wilds or improves Bemon,and s�
who commas for such projects with a conuacher(s)licensed pursuant re do Coneacsofs C
License law. �\
❑lam exempt under See .BAPC far Nis mann v
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby sRim under puuny of perjury me of the following dcclaratimm
W ve and will maintain a CeNOae of Consent to self-insure for WorkeesCompen-
sation,az provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued.
Q 1 have and will maintain Workcfs Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance ofthe work for which this permit is issued '
My Workefs Compensation Insunxe artier and Policy number am:
Cartier. 5f!t' 1fu/lp Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section eed net W compleed if the .it is fortme hundred dollars(SIM)
or less.)
1 cent),this,in the performance of the work for which this permit is issued.l dull not
employ any penin in any mmerm as to become subject to the Workers'Compensation
Laws of C.lif.odo.Date
Applicmt
NOTICE TO APPLICANT:If,after making his Certificate of Exemption,you should
become=him to the Wohefs Compensation provisions or the labw Cock,you most
,Z, feMwith comply with such provisions or this permit shall be deemed mwked.
Z OCONSTRUCTION LENDING AGENCY
[—� I bemhy affirm that Bert is a comtmction kining agcm:y for the performance,of
C3; the work fur which this Permit is issued tsm,W.Civ,C.)
1 Q Us&,',Name
;:)Z Undoes Address
CJ Q 1 certify that I have mad this application and sue that the aWm information is
1, f-" corms.l agree to comply with all city and county ordinances and stay laws misting to
0(J Wilding construction,and hereby amborim represemadws of his city to enter upon the
Cr7 above-mcmioned pmperty for inspection purposes
F LL (We,)agree to save,indemnify and keep harmless the City of Cupertino against
pq liabilities.juegmenta.cesta and cxpenus bleb may in any way urneaPitmaid City
()z in cc do
dthed 0gof Ibis renin.
APPLICANT UNDE A DS WILL COMPLY WITH L NON-POINT Issued by: Date ,� .-� �'
5 GULATI S.
V Re-roofs
Signature o(A plicmUCanuanor Dete
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or funum Wilding m eto m imfe m handle hazardous material
as dcnned by the Cupertino Municipal Cede.Chapter 9.12.and the Health and Safety
Code.se❑ a rtien 255324)?] All roofs shall be inspected prior to any roofing material being installed.
Y �7D o
T If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or forum Wilding occupant esu cyuipmem or devices which P g
it hazardous air contaminants az defncd by the Bay Area Air Quality Management all new materials for inspection.
uicq
❑Yes ;W
I have real the bar. materiasmquimmcw under Gepserh.95oftheCali(or-
niaHalthkSareyC au n .25577 and Z553a.lmdcmmd thuiftite Wilding
does not emoemly ha a rot, t s my maponsihda m dry the upon,of the
womb ret on
ermi:anon tattle brat: er. Signature of Applicant Date
_' 19 All roof coverings to be Class "B"or better
Ownerorahori'rnd agent Date-