04040016i
CITY OF CUPERTINO
`" , T
BUILDING DIVISION PERMIT
CON' CR1iCTOR4NFORMATION:,
3 ,
pUILONG ADDRESS:
PERMIT NO04040016 4040016
WNER'S NAME:
PERMIT ISSUE OATS
NGUYEN T
ONE:
SANITARY OL NO,
ARCHITECHENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� C=
LICENSED CONTRACTORS DECLARATION
Job Description
p
I hcmby affirm that I am licensed under provision Of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and promasinns Code. and my license is
I. bull fma aced effam
ENTRY (7 8 SQ FT )
LuMsc Class Lic. N
. .
DataContractor
ARCHITECTS DECLARATION
I understand my plans "I be heed as public recmdt
Licensed Pmfmional
OWNER -BUILDER DECLARATION
I hereby affirm Nat I am asempt from Ne Comrseme, Licence Law in, the
fallowing mason. (Section 7031.5, Business and Professions COCA: Any city of county
which rcqulros A Permit to ennswct. sites. Wpmw, demnlish, lir repair any aware
prim An Its issuance, also ICgtIRM1 the applicant for such permit to file a signed atammenl
Connector'. Urn. Low 9
Sq. Ft. Floor Area
ValUat On
at he is licensed puuent to the provisions of ft (Chapter
Nn
(Commencing wish Section 7000) of Division 3 of the Business and Prolusions Cmlc) or
that M is asempt therefrom and Ne toot for the alleged esampti. Any violation ref
3'JFISMrit (:r0 0
Occupancy m� e
p yw]p
Section 7031.5 by any applicants for A pemN mbjecu Ute fiPpllans m A civil PM&IIY of
not mom than five hundred dollars (1150B.
❑I,uomuot NapmpwywmyamploymwithmmuNe wiewmpenadon,
Required Inspections'
e q p
willdothewor"MiLl eawnumisnotinmendorofferadforole(Sec.7014.11.1 •
and Professions Code: The Comoscoes Loans, law dm not apply to an Owner of
pmpeny who builds or improves thercan, and who does such work leimaelt or through his
own emplaym, provided that such impMMMMu sae nmintended aroRemd for sale. If,
f- f'
however, the building or improvement is mid within one year of mmpledon. the owner.
builder will have the burden of proving that he did not build or improve fm purpose of
I
`+(
❑ 1. u awns of uolanand Freeloaders niched Comamors i.
Cod
comtm a Sm. 704 ,O antl wAtiaos Cadei
Ne pmjacl (Sr,. ]Old, Buer
ons Lbwho
Promhe
IJwdmnotapplyAn Af ny them
a
who Wildaorimprove thereon andwW
crositarmProper(
can.W tw such projema WIN•conumtoKsl Iianmd puruam tothe ContractOM1tJ
Lkenss Law.
❑tem sae r�er See .BPC (ar is n
13`-
ORKER'S COMPENSATION DECLARA
I hereby ran under penalty of perjury one of de tollvwini I cru:
self-irsum for Worker's
IAs Il mainWn• Comficamaf Consent m Campers
atlAn. u. f d for by Secdon 1700 of Ne Ut r Code. for the WrfO^n of the
work for which this permit is Issued.
uran. n mquimd by Section
haw and will maintain Woes Componsstion fma
❑ I maintainfke
3700 of Ne IAWr Code, for IW Performance of the ooh fw which this Permit Is Issued.
My Worknes Compensation Instance carrier and Policy number are:
Camer,Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
mus section Aced not be completed iftW permit is two= hundred dollars ($100)
lir les.)
1 anffy that in the performance of thou work for which this permit is bound, l ddAA not
employ Anypemon in any manner an u M become subject o de Workers' Compensation
Law, of California. Dam
Applicant
NOTICE TO APPLICANT: If. after making this Cenifica a of Exemption, you should
become subject to Nc Worker's Compensation provisions of the Labor Cndc, you must
f."wiN Comply with such proviamns or this Permit shall be doomed revoked.
CONSTRUCTION LENDING AGENCY
1 Wrcby affirm that ft. is• consmstinn lendingagcncy rnr the pArfin .of
tW work for which this permit is issued (Sr,. 3097, Civ, C.)
Lundeen Name
Lender'.Addmss
1 certify eat I have mad Nis application and aur, thus the aWve information u
Correct. I qme to empty with all city and county on inames and sure lam mlatins an
Wilding construction, and hereby auNarire repremnatiw of this city to enter upnn Ne
above-mentioned property for inspection purposes.
ro
(We) acme to cost, indemnify and keep hay the City of Cupcnst
liabilie(We)s
in M id City
oto case. andeapenscawhich mayinany myaraeagatoslhid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINr
Issued by: Date
SOURCE REOULATIO S.
e -roofs
Type of Roof
si um of Appl YCo for Date
H RDOUS MATERIALS DISCLOSUR
Will Orcapplic orfutum Wildingacupinlsmmorhamdlchuardmusmamrisi
o defined by sire Cu ino Municipal Code. Chapter 9.11. and too Health and Safety
mle,scction zs5324)?
All roofs shall be inspected prior to any roofing material being installed.
CYnsNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ino applicant or fumrc Willing aaupmt sic equipment Or device which
mil hula d air commoiosm as defined by Ne Bay Arca Air Quality Management
all new materials for inspection.
District? �\tt
❑Yea No
I have read the WantI.u`smeuriOla mquimmmmu under Chapter 6.95 of the Calif.,
ria HcalNASefcly Cade, timn25505,25533and255M.1un&m dthmifde Wilding
does nol tunely mnam, N tt u my mspomibilil m notify tW eccupant of tis
mquimmcnu .11 Me o Iuaanaar n<.maroca
Signature of Applicant Date
All roof coverings to be Class "B" or better
ow rauNori a Da