04070160 FI.NER'S
OF CUPERTWO -a5 ?F:srorr�a . t, ,� -'
ILDING DIVISION PERMIT tCO1VTRACT�nR AVFORMATION
ADDRESS: PERMIT Nb 4 0 7 0 16 0
5 GRAPNEL PL
NAME: PERMIT ISSUEDATE
HANH NGUYEN
SANITARY NO. CONTROL NO.
E:
BUILDING PERMIT INFO
AR CHITECIENGINEER: BLDG ELECT PLUMB MECH
yOu C reZ LICENSED CONTRACTOR'S DECLARATION
II berhb,air,.Net I am licensed under provisions of Chapter 9(commencing A lob Description
u with Section 7")of Division 3 of NC Businev and Pmfaadmm Cade.and my liecvcu 'IA�105i1
mmRfame and e(fea RELO ITCHEN/COFFERED CEILING
�? License Class Lle.a
t�p Due Canlsulor
rH ARCHITECT'S DECLARATION C� II
'yS � I undersand my Plena MVl he must as public=am �oo/,
B 7
1.t; Licensed Prtdeuianal pl�
3 OWNER-BUILDER DECLARATION U ®'
+� I kmhy affirm Nat I em exempt frvm 0u ConusesaYs License Law for tk
ip o (allowing rtasoa(Satiun]TOES,Businm and Rvfuctiuns CoJc:AnY city dr muntY $15000
,,S� which ropons a Permit a cmmmel.slur.Milan.dcmuluh,m repair any suucsum
prior a its issuance.Ad roguims the applicant for such Permit to rile a signed acumen, Valuation
< thm he is licensed pursuant to the Provisions of the Crannnm's License Law(Chapter 9 Sq.Ft.Floor Area
2 B (commencing with Section 7000)of Division 3 of the Businca old Prdfeainm Code)Or
3 des he in ewnpt Ncrefmm and Use hum for the alleged exemption.Any violator of _
Sation 7031.5 by airy applicant for a permit subjects An ppliant a a civil Intensity Of lye Occupancy Type
not mom Nan ave hundred dollars(5500).
1.as owner of An prapeny,W my employees with wages as their ale compensation,
will da the work and she structure is not intended or offend for aala(Sa.71164,Business Required Inspections
and Parauiora each:The eomsuars L.itttue Law ed denot apply to an owner of q p
pmpmy,w ho buil ds or improves them en,and w ho dors such work himsef r or through his
own employs.provided Nat such imioname mu see not inunded aroRhmd farsale B,
however,the building or impmvmnent is sold within ane Year of ee m ticuau,the Owner-
builder will haw:the burden of proving that he did and build or improwh for purpose of
ale.).
1,an owner of the patient,am eaeladvely convecting with Recanted convenors an
comwct the project(Sem.7014,Business sed Profestions Code:)The Cern am oh U'
us Law docs rat apply mer
an darnof property who kit"or hmprow thereon,and.
who convects for such projncu with a centres tos(a)licensed pursuant a the Cdnvacafs
License Law.
13 an m under Sc ,BkPC f Zhas
an
at Data
WORKE 'SC MPE A ONDECLARATIO I(`�
1 kreby allmo under palsy P dar cru of the fallowing dalantiood:
I have and will maintain•Cenifiou of Conant to calf-imam for Wahcrscumpm-
sation,as provided for by Second 3700 of Ne Labor Code.for the perfarmence of the
work for which this permit is issm4
❑1 bars and will maintain Workces Compensation Imwanm,as,required by Section
3700 of the Labor Cade,far the pcdaasAon of An wear for which this permit is issued.
MY Wmkeh Compensation bream nce carter and Policy numkr am:
Cartier. OF EKEMPPolicy No.:
AT
CERTIFICE DON FROM WORKERS' -
COMPENSATION INSURANCE
(Thuseed.a Iced nos k emopleud Rahe permit is fnr enc hundred dallm 4100)
of Mss.)
I certify that in the parfa mencc Of the work for which this Permit as issued.I Mail nm
emplay any person in any manner u as on beeanwabjees to Ik Warkers'Compewuon
Laws of California.Duh
Applicant
NOTICE TO APPLICANT:If.afar making this Certificate of Exemption.YOU should
become subject an the Worker's Compensation previsions of Use,Labor Calk,YOU must
,J Z forthwith comply with such provision or this Permit xhdl k rimmed madded.
Z O CONSTRUCHON LENDING AGENCY
[.n I kreby aRrm Nat Neu is a construction lending agency for lk performance of
!Yi 7 the work for which this penal is issued(Sce.3097.Civ,C.)
W Q Larobe,Nune
lender's Add.
U 0 I ondry Nat I lawn read We application and All out the above inroarman u
W comm I cpm a comply with all city and county okinancee and sea Inco selmat le
OU building m)agree to nd hereby saw.
imueop ler representatives of this city arnmrupon the
r W shove-mentioned propuny for inspection Puspaus
(We)ages a ave.indemnify eek keep hannlrsd sk City ofagainsta against
E"y Easiiilmajudgmenu,casns and expemth
es which MAY any way acme ageintsaid City
V z in comem made:or the gruNng of Otis permit. D e
�-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURC Lyq/7_IIO�NS�.//
/ P '// l^ ✓t l��l✓ Re-roofs
Signa of A"Heam✓clUtranor {{�� °Pet T of Roof
HAZARD SMAfbUALSDISCLOSURE Type
Will tie applicant or future building mupant ware ar handle hmardous maudel
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cone,Section 35533(a)? a All roofs shall be inspected prior to any roofing matF being installed.
❑Yen �@"
Will the applicant or future bonding occupant au walpmhnt a1 devices which If a roof is installed without first obtaining an inspection,I agree to remove
it barna ad air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dimrica? t
❑Yes �Nm
I hove mad the bkum aur aamriw,mmo m ass udder CTupur 6.95 of Ne cabror-
nuHWNhSafctYCodc,Saxons 15505.23573 anJ253Jd.lvedcrnand NPi(LOU Wilding
Jas ret earrtnd,how a lama that it u my rommu ihilitY a mo(Y the naupus of the _
regmiame ikmet 'ora issuance ofn Ccrtirica o cm ' cy. Signature of Applicant Date
All roof coverings to be Class "B"or better
r ar aotirofisd agent