03040111 CITY OF CUPERTINO ' ' x'77_71
BUILDING DIVISION PERMIT 6lJdNTTkAdT,0n INVURMA"PI0 9'''
BUILDING ADDRESS: HIEN Q. TRUONG FERMI I NO 03040111
Ts11
ER'S NAME: PERMIT's"b2 2 0 0 F3
N Q . TRUONG
PTIONE: SANITARY N0. / CONTROL NO.
ARCHITEC IENGMEER: BUILMNO PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nal 1 am loaned under provisions of Chapter 9(commencing Job Description
i wit Section 7000)of Division 3 of the Bodes=and Pmfcaaiune Code,and my license is
"p Fr imm�mmaa. Lic.N
effectj jg? Lmene= REVISION--IN HOUSE USE ONLY
Dae Canbacmr NO NEW PERMIT ISSUED, ORIG. 402090022
ARCHITECTS DECLARATION
a� I understand on,plem shall M used as public acama
7yU
c C L'u:emeJ Pnsfessionel
Oat I am exempt
from
m DECLARATION �\
F I bereby affirm
that I am exempt(rum to RATactors License Law for the
p O following ressan.(Section 7031.5,Businms and Profession Code:Any city m coumy (+
wg� which mquira a permit m com=et altar,improve,demolish.at mpalr any structure �l
s-Zia
prior In,its issuance,also requires the applicant for such permit o file.,igncdautmcnt
FFFA thV i e is Reamed f ursuant'.the proAstmi.f to Con=dor's License Low(Chapter 9 Sq.Ft. Floor Areanation
N (commencing with Section 7000)of Division 3 ofte Business and Professions Cat)or
$ test M is exempt tem(ron and the basis for to alleged exemption.Any vioh0on of 0
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not marc Nan five hundred della.($500).
❑1,as owner of to property,or my employees with wages as their sole compensation, 31602065 ' 0 0
will do to work and the structure is not intended or offered for sate(Sec.7044,Business }p�seOtf(C d Inspections
and Profesdmu Code:The Contnctoes Lune es= m Law ducat apply an owner or 101 — FOUNDA 1 yl8
property who built m improves; co
tern,and who doessuchwork himselfortrough his
own employees,provided that such improvements are not intended=offered forsads.If. 102 — PIERS
however.to building or improvement is sold within one year of completion.to owner-
builder will ban to burden of proving that M did not Mild or Improve for purpose of 103 — UFER
ala')' 104 - REBAR
❑1,as owner of to prupost,am exclusively exhaust it licensed co beers to 10 5 — ANCHOR BOLTS
construct the project(Sec.7044,Business and Professions Cade:)The C=vado's U-
came wdoes notapply man owner ofpropeny who Mudsmimproves tenon.and, 106 — SEWER & WATER
orm cu for such projects wit a contnemr(O u
licensed pursuant to Contractors
neLxw. 202 - UNDERFLOOR PLUMBING
®lam exempt an&,se"
agPCfarthismamm 203 - UNDERFLOOR MECHANICAL
I Nor" Date
WORKER'S MPENSATIOND' ATION 204 - UNDERFLOOR FRAME
I hereby salon under penalty of perjury ane of the following decimations: 205 — UNDERFLOOR INSULATION
❑Than and will maintain.Certificate arconsent as self-imuse forworkeracompen. 301 — ROUGH PLUMBING
ation,M provided for by Section 3700 of to Labor Code.for to performance of the 302 - TUB & OR SHOWER
work for which tis Permit is issued. 303 - ROUGH MECHANICAL
1 have and will maintain Workers Compensation Imtumce,as required by Section
37W of to Labor Codc.for tc Performance of to work for which this permit is Issued. 304 — ROUGH ELECTRICAL
My Workers Compenation Irsurmce artier and Policy number art: 305 — FRAME
Carrier. Policy No.: 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE 307 - INSULATION
(IMssccG=reed not Mcompleted if0e permit is faro=hundred dullem(g1IX) 308 - SHEETROCK
am") 309 - EXTERIOR LATH
1 certify that in to performance of the work for which this Pennies u issued,I Nall not 310 - INTERIOR LATH
employanypersoniran yl man=r en.mIn subject to ftWorkers'CompensationGws of California.Dap
AppOa0r—� - 'w- 311 - SCRATCH COAT
NOTICV APPLICANT:If,star ing this Certificate of Exemption.you should 313 - ROOF NAIL
becomes jeet'.te Worker's Compemation provisionsof to Gb=Cedc,you mull
J,Zforthwith comply with such provisions or this Permit shall Mdamedrevolted. 501 - FINAL ELECTRICAL ENERGY
zo
CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
Ihereby affirm to ft.itacomtmctor leading agency far to Performance of 503 — FINAL MECHANICAL ENERGY
CL> the writ which tuPermit uWood(Sec.3097.Civ.C.)
Lumber's Name 504 - FINAL BUILDING ENERGY
{T]Q
jz <mdersAdee 505 - FINAL ELECTRICAL
U p I certify post 1 ban read to appliauon and sun that f aMve information Is 506 - GAS TEST
Ey correct I ague to comply with all city and county entrances and sum laws misting'.
pU Wilding consaraction.and hemby amthmin representatives of this city as color upon ft FIN PLUMBI G
[Tl above-mentioned property for imPedian leap ha 0 8 FIN L
G
(We)agree to ave.indemnity and keeper. tita City of CupeNno against
IA liabilities.judgments,custs and expenses which may in my way scenic against said City 5 /
U Z in consequence of to grafting of tis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by:51 - NG Date
SOURCER GULAGONS.
— C✓l Re-roofs 772
602 - OOF PLYWOOD NAIL
. name ofAppficmUCanRDO Dan Type 6(#3 — ROOF BATTENS
HAZARDOUS MATERIALS DISCLOSURE ofR
Will to applies.,or to=building occupant a..or handle haramous material . 604 - ROOF IN-PROGRESS
as deo=d by the Cupenin.Municipal Cade.Chapter 9.12.and to Halt and Safety
.Section 25532(+)? f/ All roofs shall be inspected prior to any roofing material being installed.
❑TTI [Rf+
Will the epplicrstorfu,um Wilding occupant a=equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit h.dous air amuse irents as defined by the Bay Ana Air Qaliny Mmagcmcnt all new materials for inspection.
Dimict? 1/
❑Yes U�ss'u
I have mad to hmamtmsmatariau mquimments under CTaptar6.Y5 o(Ihe Gli(or
mice Haltg:SafctyCodc.Savour25505.25533vW2553a.1undcmwW oiflh Wilding
dos not currently bate a toom.that it is my responsibility m notify occupant nr to
myuirOmcu khmuslEcmelpdartuiuumaafaCerdfiamof(k�apmcy.- Signature of Applicant Date
Owwnerorauta`iedage >D000. All roof coverings to be Class"B"or better