03110085 P CITY OF CUPERTINO �+ '+ " ° '%'` v
BUILDING DIVISION PERMIT CONTRACTORINFORMATION.,..
BUILDINGADDRESS: HIEN Q. TRUONG PERMITNO03110085
` 10628 RANDY LN
OWNER'S NAME: PERMIT ISSUE DATE
EN Q. TRUONG 11/17/2003
ONE SANITARY NO. CONTROL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
;Oo LICENSED CONTRACTOR'S DECLARATION
m C I hereby from that I Am licensed under pmvtuom of Chapter 9(commencing lob Description
to with Section 7")of Division 3 or the Btrommmd Professions Code,end my license I.
>>y I.full foeemmaffect. TEMP POWER -
j'9? License Class Lic.0
O Dam Contractor
f �lu ARCHITECT'S DECLARATION
y _r 1 understand my plans mail M used public records
s o t; Licensed Professional
3 OWNER-BUILDER DECLARATION
8 I hereby affirm that 1 am exempt from the Cororanar's License Law fnr the
COO O following mama.(Section 703 1.3,Business and Poremiuns Cale:Any city or county
�$ which requires a permit to ennnrun,Alter,improve,demolish.nr repair any structure 2 0 0
i<
poor it)its issuance,also requires the applicant for such permit to Bit a signed*In inact
2iO that W is licensed pursuant o the previsions of Ne Contractors License Low(Charter 9 Sq.Ft. Floor Area Valuation
2p$ (commencing with Section 7")of Division 3 of the Business and Professions Code)or
3
That he Is exempt thcicfrom end the buss for the alleged exemption.Any violal'ion of
Section 7031.5 by Any applicant for A permit subjects The applicant to a civil penalty of of 0 Occupancy Type
not more Than low hundred dollar,($530).
0 L As owner of Ne properly,or my employees with wages a their sole compensation,
will do the work,and the structure is not intended To ffmd far sale(Sec.]844,Business
end Professions Code:The Comnctols License law docs not apply to an owner of Required Inspections
prepcny who builds or imprnves thereon,and who doessuch work himself or Through his
own employees,provided that such impmvemenu ere not intended proffered ferule.If,
however.The building or improvement is sold within enc year of completion.The owner.
builder will have the burden of proving to he did not build or improve for purpose of
sale.).
0 I,as owner of the property.am exclusively contracting with licensed convenors to
was,La the project(Sec.7044,Business and Professions Code:)The Cenvactor's Lid /
who law coca not apply to an owner of proper(who Wilds or improThe uttram,and /gpyZ/
who contracts for such projects with acanTncmr(s)licenutl pursuant to to Convacloh
License Law.
1 Am exempt under c. P C for this rcazon
0 r i so
WORKERS COMPENSATION DECLARATION
1 hereby&Man under pens)Ty of perjury m¢of The following O clarnions:
1 have and will maintain a Cer ificate of Consent to ulydrsum for Worker's Compen-
1c,
on,u provided for by Section 37M of Jut labor Cade,for the performance of the
rk for which This permit is issued.
1 have and will maintain Worker's Compensation Insurance,m ani ircJ by Section
p of The Labor Codc,for the pertormance of The wed for which This permit is issued.
Worker's Compensation Insurance cattier and Policy number am:
rtier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W complowd if the permit is for one hundred dollars(31(ar)
or less.)
1 coolly Than in the performance of the work for which this Permit is issued,1 shall not
employ any person in any manner sr,az to become subject o the WorkersCompensation
Laws ill Coltrane..Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenincue or Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Cale,you must
z foMwi Tb comply with such provisions or this Permit mall be deemed raveled.
OCONSTRUCTION LENDING AGENCY -
1 hereby.1111.That Nem its eornwednn lending Apeay for The pmerurmence of
'e On work fur which thio permit is issued(Sec.3097,Ci,C.)
Ig1 0 Lender's Name
z Under.Address
U O 1 cenify Nat 1 have read this application and sum That Ne above information is
,Uy f come,.I agree to comply wit all city and county ordinances and sou laws elating to
DU building eonsvuction,and hereby authors rcpresemalives or this city to enter upon the
;T+C show-mentioned Noisily for inspection purpeus
(We)Agree To save,indemnify and keep harmless the City of Cupenino against
rF.r rq liabilities,judgments,costs and expenses which may in any way acerae against mid City
U Z in consequence of the graming of This Permit.
^ APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: _ Date {'
SOURGULAT10N5.
L/ Re-roofs
Siltriliturn,ofApplicaDataHAZARDO Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant m fpwre building occupant stem or handle hauNous material
az ecfincd by tc Cupenln.Moore 1 Coda.Chapter 9.12.end the Health and Sarcly
oJc,Scction25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
O Yes u
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
It ha'urdeus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
iuricT7
DYcs ,
1 have read the hautdnu,mamrixls requiramenu under Chapter 6.95 of the Calif.,
nice Health&Safmy Codc,Sections 25505,25533 And 25534.I amarmnd tutifthc Wilding
Joel a.,cannot),haw A mnenL Net it i,my reapapibiiby to notify the o¢upanl or Ne
mgaimmcnts whim most W me lnionn issuance ofa Ccmficampf OcwNmcy. S ignature Of Applicant Date
Owner ser as agent Omc All roof coverings to be Class "B"or better
' CITY OF CUPERTINO �
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TEMP POWER D 3
UPETI� INO PERMIT APPLICATION FORM
APN # 302 U Dater / — a3 07
Building Add lrJ�ss: /
Owner's Nam/: (�/ Phone#:
��l�'1 I 0 /'1
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building)Permit Info:
Elect C�
Job Description: rjQrn 0 tti�T
Residential / Commercial ❑
Cost of Project: S� /
QtY. .
A ca Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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