03020048 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 4CONTRACTORIN1�'UkLMATION
+ a,•�.^_ O wN Bm,anu. uac..FL"s#9' II
BUILDING ADDRESS; PERMIT NO.
HIEN Q. TRUONG
OWNE S - PERMIT L55
3 c w
SANITARY OL NO.
ARCHITF.0(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
a00 - LICENSED CONTRACTOR'S DECLARATION
� I hereby SM=inn 1 am Balled ander provisions of Chapter 9(commencing _ - Job Description
0 with See' ")of Division 3 of the Busin d Pafeulons Code,and my license is
in full f nd effect.
5gg Lia.ae l.4 Lld,4F - DEMO APR 1 O 2003
!!211tg Dore ARCHITECTSDContracW ATION PERMIT ISSUED 03/20/2003 .
l9Ridsundmypiemslullhestudaa(wIB(crecnrm PERMIT PRINTED IN ERROR 02/12/200BUILDING.
i,, Licmued Pmressiunel -- OWNER-BUILDER DECLARATION
gr 1 botchy affirm that I em exempt fain the Contractors Liccnu Law for the t
o O following reason.(Section 703 1.5,Business and Pmfeaimn Code:Any city or county s
$F which requires a Permit to annslacl,eller,imprssve,demolish.or repair any structure
p prior as its issuance,also nuuimnhe applicant for such permit to rile a.igned aalement
e0 that he islicensed Portman tothe provisions ofthe Comncmr'aLiameLaw(Chapter 9 Sq. Ft. Floor Area Valuation
$ (commencing with Section 7(X0)of Division 3 of the Business and Profession.Code)or . -
that he h exempt therefrom and Ne bash for She alleged exemption.Any violation of
Section 7031.5 by any oppliunt for a permit ubjects me applicant to a droll penalty of
at more mu m
Bw hundred doll ($500). , . APN Number -!* my Type
❑I.as owner of the pmpeny.or my amploysu with wages or meirsele compensation,
will do the weds.and mestuctnte to not intended or offered fanale,(Sec.7044,Business 31602065OO Required Inspections
and Professions Cade:The Con.mem.Lt..Law dos not apply m an owner of . q -
prupeny who buildsor impraves thertan,and who deeuuch wink himself or iduough his
own employees,provided that such impmvcmenu am not Intended orartemd for Sole.if.
however,Me building or lmpmvemut Is mid within one year ofcompledon.the owner. NO ASSIGNED INSPECTIONS, -
builder will have the burden of proving that he did not build or Improve for purpose of
"U.).
❑1.as owner of the properly am exeluilvely contracting with licensed containers to
construct ds project(Sec.7044,Business and Pafesslons Code:)The Character,U. -
emse,Law does not pply to an owner of property who klld,or improves Merton,and,
who cantracta far such projects with a con acmr(U Ilcemed pursuant to the Conuecmrs
License law.
❑I on aem�pt/�ntler Bee .B A P�f,this a.
I�(N/l _Doe
WORKER'S COMPENSATION OECYa0. TION
I hemby&Man under penally of perjury arc of She following decimations:
roe and will maintain a CerOriuta of Covent to telf-insurc for Workers Compen-
,all."as u provided for by Section 37M of the labor Code,far On,perfamem.of the _
work for which nth pencil is issued. -
❑I haw and will maintain Workers Compensation Insurance,or required by Section
3700 of me labor Code,for me perfarmuee of the work for which this permit 1.issued. '
My Wolcc'.Compensation Insurance caner and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' -
- COMPENSATION INSURANCEor less.) ,
(this Section need not he completed if the permit is for one hundred d.:I.(SI(Itl)
I ardfy that In the pe rmiroace of the work far which this permit Is issued,I.hall nut
employ any person in any manner an as in become subject to the Workeri Compenutlon .
Laws of California.Dna
Applicant
NOTICE TO APPLICANT(If,after making this Cer ifcam of Exemption,you should
become subject to the Worker's CumPensetlor provisions of the Iakr Code,you must
,JO forthwith comply with such provisions or this permit shall k deemed ranked.
h CONSTRUCTION LENDING AGENCY - -
E~ I hereby affirm ma inert is construction lending agency for the performance of
fk7 the work for which this permit Is issued(Sec.3097,Civ.C.) .
W Q lender's Name
0.. z Lender,Add.
(.J Q I certify that 1 have mad Lois application and seta that the all information is ..
ty F correct 1 arm to comply with all city and county oNlnanua and sure lawn reining to
0 building construction.and hereby authmta mpreuntun;of this city to enter upon me
>� alwvcmemioud property for inspection performs.
(We)agree to Sats,indemnify Sued keep harmless the City of Cupertino galnst
tito liabilities,judgments.casts and expenses which may In soy way acme against Sold City
C)Z in concomitance of the Starting of this permit. v/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs .
i sort of AppliuMCoarrumr Data
HAZARDOUS MATERIALS DISCLOSUR - Type Of ROOF
Will the t eppl pordnaant or future building Occupant state or and the
Health
hus and Safely -
al
u derived io rise CLpeninh Municipal Code.Cheerer 9.12,and tint Hetlth entl SeRty
Code,Section 255J2(e)7 CK 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
Will the applicant hr future building occupant sou equipment hr devices which p g '
aumous Sir contaminanuu de ad by the Bey Amo Air Quality Management
District? all new materials for inspection.
El Yes s ,
I have mW the hazardous mmu b srequirement under Chmuur 6.95 of the Califon
is Health or Safety Code,Sectiuv 8505,25533 and 25574,I undcatand mat ifmc broiling
it..not curmnlly have a scent Loin It I.my responsibility m nadf the,Occupant of due
mqutheme to which must k met PH., Seto ..ficcnifsaof cu cy, Signature of Applicant Date
owner ora axe eFanl 5 ❑ e - All roof coverings to be Class "B"or better