07100166CITY OF CUPEKUNU
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19"i01 gTm7FT\Tq ("REEK RTVI]
'ER'S NAME:
PHON .
MRVi Nf��,P.�c�{'R—
ARCHITECT/ENGINEER: �F.�C1" `v f / Q
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic. #
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to concoct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
El 1, as owner of the property. or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 I. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and .
who contracts for such projects with a conLractor(s) licensed pursuant to the Contractor's
License Law.
0 lam exempt under Sy- B & P C for this reason
er
Date
I hereby affirm under penalty of perjury one of the following declarations
511 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
] 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. - Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so orne subiect to the Workers' Compensation
Laws of CalIf9ta.. ate
Applican'
NOTICE TO APPLICANT: If, making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signature of ApplicanVCon uau
HAZ OMS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
ac defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
le, Section 25532(a)?
0 Yes jRiqo-
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
(:1 Yes 211
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currl�'' have a tenant that it is my responsibility to notify the
eettroccupant of the
requirct�artfs�J�eh- st be mel prior to issuance of a Certificate of Ocl_p ncy I. ' t
Job Description
INSTALL ILLUMINATING SIGN
r'q. Ft. Floor An
APN Number
31620087.01
Issued by:
Re -roofs
Type of R,)of
uatlon
Occupancy Type
Required Inspections
All roofs : hall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
g I nature "PP licant Date
All roof coverings to be Class "B" or better
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN 31620087.01
DATE ISSUED.......: 10,'23/2007
RECEIPT #.........: BS000003061
REFERENCE ID # ...: 07_.00166
SITE ADDRESS .....: 19`_-)01 STEVENS CREEK BLVD #103
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER ............: VU & BAOTRAM TRUONG
ADDRESS ..........: 19501 STEVENS CREEK BLVD # 103
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: VU L TRUONG
CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096
COMPANY TB]) - TO BE DETERMINED
ADDRESS ..........
CITY/STATE/ZIP ...: ,
TELEPHONE ........
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
----------
NEW BAL
----------
----------
BENERGY
-------------
PERMIT FEE
----------
104.76
-----------
50.28
----------
0.00
50.28
0.00
BPERMFEE
VALUATION
4,000.00
104.76
0.00
104.76
0.00
BPLANCHK
PERMIT FEE
104.76
139.80,
0.00
139.80
0.00
BSEISMICOM
VALUATION
4,000.00
0.84
0.00
0.84
0.00
EPERMITFEE
FLAT RATE
1.00
40.79
0.00
40.79
0.00
----------
TOTAL PERMIT
----------
336.47
----------
0.00
----------
336.47
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
336.47
---------------
336.47
VOICE
ID DESCRIPTION
--------
101
----------------------------
FOUNDATION
104
REBAR
304
ROUGH ELECTRICAL
514
FINAL PUBLIC WORKS
REFERENCE NUMBER
--------------------
#227
VOICE ID DESCRIPTION
-------- ----------------------------
103 UFER
105 ANCHOR BOLTS
505 FINAL ELECTRICAL
CITY OF CUPERTINO
SIGN
CUPERTINO PERMIT APPLICATION FORM
APN # 3 f Oc� U O F-1-7. 01
Date:
Building Address: + 'c� p ( Sit -�� sVb> ln3
Owner's Name:_
Phone #:
Contractor: F�+v�DI-e, cry
License #: _ /� S^ Qct g 931
Contact:
Phone #:
Applicant/Contractor:
Sc-ismic Commercial
Building Permit Info: T -f1KTP►xkr (1L`' T LL U f Af NAi t Vit, 41C,�
Bldg Elect Plumb Mech
Job Description:
Residential: Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation:
Type of Construction:
Occupancy Group:
Qty. if
ADDlicable
Fee ID
Fee Description
Fee Group
BENERGY
Energy
BUILIDNG
BPERMFEE
Bldg Permit Fees
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BSEISMICOM
Sc-ismic Commercial
BUILIDNG
jC EPERMTTFEE
Elect Permit Issuance
ELECTRICAL
BREMSIGNAD
Rndl Signs Add Branch
ELECTRICAL
BREMSIGNS
Rjndl Sings, Marquee
ELECTRICAL
r BUSLIC
Business License
BUILIDNG
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