06010023 CITY OF CUPERTINOh '� I Fb E '�a �«
BUILDING DIVISIONPERMIT nIC11,'T�12A. TQ `,`, MZI;!
BUILDING ADDRESS: REAL ESTATE BUILDERS INC PERMITN0.06010023
21150 HAZELBROOK DR
isNER'S NAME: PERMITISSUEDATE
is
ANDY NGUYEN MINH DIEU THI IFU351 LEVIN ST 04 /11/2006
111ME: SANITARY NO. CONTROL NO.
(408) 829-2805
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG O PLUMB MECH
Sop LICENSED CONTRACTOR'S DECLARATION Job Description
1 Wmby+farm that I am licensed under provisions of Chapter 9(commencing
Swith Sectim,TOM)ofDivision 3ofthe BusinessandPrafassmnsld
Code.dmylicenseIs
I.full force and affect. SFDWL-2 STORY 3 , 144 ' LIVING/GARAGE 462 '
jLj= License aM. Lle.N
Dam Canl 5/24/06 CORRECTED SQ FOOTAGE/VALUATION
' ARCHTIECI-SDECLARATION PER BOB S & OWNER MINH DIEU VU
I I undernsnd my plans Mall be used u public records
5 m�ryu
ma
Licensed ProfcssmMl
OWNER-BUILDER DECLARATION
1 hereby a(Rm o n I am,Bumps from the Cstions Co License Law for de
coo fallowing reamer.(Section 7U31.5,Business and Ra(asioM Cade:Any city or caumy,
9�+ which requires a permit at conmusret.alcor.'vnpmve,demoted,err mpoir any smuctum
-iy prior In its Women.also requires the applicantfar such permit a file a signed summer
F G Nu he is licensed purmantatite pmvieamaf the Canuacmr.Use.Mw(chapter9 Sq.Ft.Floor Area Valuation
C� (..ad.&with Section 700M of Dnssmn 3 at Use Business and PmrasaioM Code)IX $691354
e;g that he is Camara Nerarmm and don bass,for W&titled tampdoc MY vi,,Won of
Sccdw 7011.3 by Any Applicant for a permit subjects Ne applicant a ernil Pointy of APN Number Occupancy Type
set more duo five huedmd d.IWA(3500).
❑1,uwmer of the property.or my emplayees with wages as them sale cmnpemadon, nozz
will do the work.and me suunute s,aonimnded or anered far nm(San.7044.Butlnus Required Inspections
W Profams.Cade The Coarw acmrs Ll laCons ml apply a an"Muensr of q P
pmpeny Yho build i IXimproves shemoa,and whadoesma,wick Wasulf ark through his
Own employ=.provided that such imp avemau art nm intended oroReml for ale If.
harper,the building or improvement Is mid within me year of coapmuoa,Coss marm-
Wilder MB haw the burden of proving that be did set build or improve for puryum of
sale.).
❑1.M awner of Ne property.am exclusively communing with licensed conmrrman An
mamLi-
cam
La the pmktt(Secapply
7044.wner of rod ray who
Cade:)The tart ft oh and come law Cora not apply m ts with
a of property sons Wilds or improves demon,sed.
who contracts for such projects YiN•eonvaemr(s)IlaMed pursuant to site Convactars
Liam.law.
❑1 am exempt undo Sec .B'&P C fa this recon
Data
WORKERS COMPENSATION DECLARATION
I bCRby alarm under penally of perjury ane of the(allawmg declmminu:
❑Ih,...Wwlllmainmin&CeninumofComnimmlf-IuumrarWorkersCwnpen-
titian,u provided For by Section 3700 of Use labor Cade,far Na performance of Ne
war for which this Permit is Wood.
❑I have and will maintain Worker's Compensation,manse,,u required by Section
3700 of the labor Code,far the perfnmance of the war for which this Permit is iasuad
My Workers Compensation insurance carrier and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
Cridi sectim,ped not he completed li the permit Is far.hundred Oil.(SIM)
or In.a)
I certify that In the performance of the war for which Nb Mmdl is broad,I&lull not
employ any Perron in any manrmran as In become subject to the Workers'CDmr muuk n
Laws of Cslifomia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the Labs,Cod,,you mMs
O forthwith amply with such provi.iom or this permit shall be deced re
mvoked.
z CONSTRUCTION LENDING AGENCY
[r 1 hereby ahem that Nem 1,a construction lending agency for the performance of
a r7 the work for which this permit Is Issued(Sec.3097.Civ.C.)
W 0 Lenders Name
7 Z I<ndmrs Add=
U Q I=try this I have reed this application sed sum that the above Information At
IL F COMM 1 IScee to comply with JI City and county aminsu=and ale laws mining m
0 U building Conswction.and hereby authorise mmemmatives of Nis city to enter upon the
W ahme-mcodund property for inspecuon purposes.
gy (We)agree to save,indemnify ad Intel,harmless the City of Cupertino against
m.y q1 liabilities,judgmanta.cons and expenses which may in any only name Against said City
U Z in con.aquance of the granting of this permit.
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. -
Re-roofs
Siganure or Applicaoo'Conuecar DataOf Roof
HAZARDOUS MATERIALS DISCLOSURE 1Ype
WIII NC Applicant or run=Wilding occupant mare or handle haardons material
an defend by the Cupertino Municipal Cade.Chapter 9.12.and No Health and Safety
Scrian 2533:(.)? All roofs shall be inspected prior to any roofing material being installed.
CYM ON.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or fortune Wilding odmpam use equipment Or devices which
emit Imembous air canumiMnu a delved by loss Bay Arc Air Quality Management all new materials for inspection.
District?
❑Ya ON.
Ihavemad NehuArd s dabmequimm underChtpmr695ofNe Califor-
ns,Haalth&SafcnyCaCoe.Stt9au25305.25533.M25334.lw*m mm NniHlc Wilding
dna om curren0y have a letters.Nat la s,my mryowhnity a mmiry t e asuPmt of de
requirements which most be met prior m)saancc of.Ccrufaue of Occupancy. Signature of Applicant Date
Owner IX auNarismd agent Data All roof coverings to be Class"B"or better
CITY OF,CUPERTINO 4•�*« I=�' u"b�*°" '�
Buaomc BrvlsroN, PERMIT k�21w »T", ", NFORM.r�.'1'IONi
BUILDING ADDRESS: PERMIT NO.06010023
21150 HAZELBROOK DR
NEWS NAME: PERMITISSUEDATE
ANDY NGUYEN/MINH DIEU THI VU 04/11/2006
NE: SANITARY NO. CONTROL NO.
ARCHI77=MNGINEER: BUILDING PERMIT INFO
BLDG BUILDING
PLUOMB MEOCH
i j p LICENSED CONTRACTOR'S DECLARATION lob Description
1 b+ 1 hereby affirm Nu 1 Am licensed under provisions of Chapter 9(mmmeming P
Sj with Section 7")of Division 3 of the Business W Proreasium Code.and my license is
mmnmrceandArf y SFDWL-2 STORY 3 , 233 ' LIVING/GARAGE 440 '
iqz uannwclssa.�li—Lk.•
7W
ARCHITECTS DECLARATION
1 unticmmnJ my plans shall he used AS Public rtcnrN
yyU
a G
Licensed Pm@vaionel
`y3 OWNER-BUILDER DECLARATION
ZOhereby.(Sero o n 1 am uusin from Uu Contractor's L cense Law for the
ZOO following moon.(Saito 7W LS Business and Professions Calc:Any tiny or manly
5$ which squires n e,a to to ludims 1,alms Mprow,demolish.t sir mpalr any tatemum
pri«toitsisswnee,Shu require the appliant for wch pcmitmfik asigned statement
<
due heblicensed pu uant to the povisionsoftheContractor''sLimmeLaw(Chepmr9 Sq.Ft. Floor Area Valuation
at p (commencing with Section 7WWof Division 3ofthcBusiness And Prefessomrude)« $697510
y $ dist he Is aampt therefrom and the bub for the alleged eaempdom Any vlularlun of
Section 7031,5 by any applicant her a permb Subjects the applicant to a civil penalty of APN Number Occupancy Type
Act mom Nan Bw hundred dollen(SSW}
❑I.u owner o(the property,«mY eroploym with wags u thew sole compenwtion,
wits do tht woek and dreswerwebnatintended«nrteted mrsalc(s«.7aa. Required Inspections
and Profession,code:The consensuses 1 I==law ma and apply to an Son"of 9 P
property who wildsar improwa tereon,and wmd«sa«Jt w«k himself«through his
ownanployces,provided that Such improwmenu are Act into «oRered forum If.
however,the building or improvement bsold within we Ysu of campktioo.the owear-
badder will haw ft wtdan of proving that M did Ant wild Ar improve for P OPUS of
Yk.L
❑1,a owner a the property.am eaelusively eonuacting with]sassed contractors b
construct the project(Sec.7044.Business and Profailou Code:)The Contractors Li-
cense Law d«]ml apply in an owner a property who wlida or impmwea tKRmh and
sem ca i nm f«such pmjem with a m on cmr(U licensed pumas to Ne Conuuwh
License law.
❑lamucmplundm See .Bl PCf«dabreamo
Data-
WORKERS
auWORKERS COMPENSATION DECLARATION
1 hereby SRum under penalty of perjury one,of the following d«Wuions,
7E!w
m and will maintain aCertfinemof Gomenl m hell-Imwm f«WorbersCompm-
u provided f«by Section 37W of the Labor Code.f«the per(arme«e of theor which Nb permit b ivied.
,w and w01 malnnut wanes compemaden Tnswwue.a mquimd by section
flm Lab«Code,f«the peRormanaof the work f«which this permit b wad.
orkers Compensation Imutm r,carder and Policy number ars:
'. N/A Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
This aeitim recd het he completed if Ne permit is f«oac hundred dollars($1 00)
or texts.) '
1 certify dent in the perfotmu¢e of the won for which this peahen is Lmetl.I shell not
employ any person in my manner u boom wbjento Newurken'Compewdan
Saws of Califamty�D�L CSToATLt—�8ax t�DSRf-�A G.
Applicant R
NOTICE TO APPLICANT:If,Spur making this Certificate of Emmptinn,you Amid
become subject to the Worke s Comp msidon provisions of the labor Code.you mass
vJO forthwith comply with Such provisions,err this Permit shall k damcd Services.Zr► CONSTRUCTION LENDING AGENCY
Fs (hereby aRrm duet dem Is a construction lending agency for vire perfunnurueof
(>:9 the wan far which deist Permit b issued(See.3097,Civ.C.)
W�Q Lenders Name
1<nder's Addlus
U 1 mthly that 1 ban stead this application W sum dol the Shaw Information b
[1.F correct.l agree to comply with all city and county aNioanms AM site laws rusting In
�U buildingconstruction,and hereby autmrin representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
G (Wc)agree to haw,indemnify and keep lumnleu the City of Cupertino against
v.y cA liabilities.judgments.costs andexpenmS which may in my way acme Agalmt said City �y
U Z APPLL CANT UNDERSTANDSf AtND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RECULATW
Re-roofs �-
SignatureofAppliem✓Canuactar DAM Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future wilding occupantsmre«handle hazardous material
As defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
We.Section 15531(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu [9 No
Will the applicant or future building occupant um equipment or cavities which If a roof is installed without first obtaining an inspection,I agree to remove
cmlL hazardous air eom usinanu AS defiocd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yu 9Nu
1 bac mad the hazaphats mamdab requirements under Chapter 6.95 or the Califon
nia Health&Safety Cade,Satiate 15505.25533 W 75534.1 uMemand that lfdu building
dace not currently hoe a anent,that It k my rupomihility to notify the Occupant of the
requirements M,��nmaatwmet prior wissuance ofacemnateofampwmy Signature of Applicant Date
Owner or authorized agent Data' All roof coverings to be Class"B"or better