06010153 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C0112'ACQR TNFORIVIATTOIV ,'
BUILDING ADDRESS: PERMIT NO.
06010153
O241R1sBQ'E:HAZELBROOK DR PERMIT ISSUE DATE
AN
D U EN & MINH DIEU TH VU SANITARYNID4 10 2gp�LNo.
ARCHITECTIFNOINEETI: BUILDING PERMIT INFO
BLDG ELECTO PLUMSO MECH
O
�p LICENSED CONTRACTOR'S DECLARATION Job Description
hereby affirm Nat 1 am licensed under prevision of Chapter 9(commencing
with Section 7000)of Division 3.1'the Business and Profession,Code.and my license ie
in full forte and teff L g g 3 2 3 S
Sz ucenacl - Lb,g
Conlrxlar a Av DEMO (E) HOUSE t?
p De¢
g As hall W me DECLARATION \
iu� IuMcrwnd my plan aesilMuseda Public rtcaN,
yU V
Licensed Pmfcssiovl f'a
Oal I am exempt
from
mDECLARATION
e f 1 hereby acam .(Sero that 1 1. exempt from se Contractor's e:Any
Law fou the \(�
I O following moon permit
t ](D Cons5.truct,
t,star. and Improve.
de nv Code:Any eiy of cwnty
pri
3(ryVi which t its beco a permit m pdoc,the
plea improve.demolish,or.pair any structure
CY that het gummed p-rIWnt at he BMvisionsof fM Cotonbe rmll.cesm pnedaYmmenl
"eo that(comhe pursuant se the pmWcimu NtheeBuinessadProa law/ChaPur9 Sq.FI.Floor Area Valuation
1; "heir staingmps
withSenian]Ondth00) Divisions then Bund essandon.Myon Ctumat
3— Na he b esempl tberUrom and de buss fm the sibgrd exemption.My Wolauco of
Section 70313 by any,applicant far a permit subjects the applicant.a and Penalty of APN Number Occupant
nm ma.Nan B.beaeded dollars(3500).
DI,uown.oftheproperty,amymoployeawWwageu Neuwka pe dans
willdo the work and thesuoctum is colonnaded or offend faeae(Sec.7061,Business
and Proportional;code:The Commucwrs Lfceve Law does,set apply to u owner of 3 2 6 5 5 0 2 7 . 0 0 Required Inspections
property who builds orimproves thereon,and who dnes inch work himself ear through hit
own cmploycn,provided that such imprmemsnu ase cot intended oranercd forsale.If.
however.the building or Improvement is sold within aro yea of completion,site awnv-
builder will lean the burde,of proving that he did not build or improve for purpose of
ole.).
D I.as,cones of the property,w exclusively cacosedng anis licensed conuamom to
mammas the project(Sec.7044.Business anti profession Cade:)The Contractor's U.
cave Law dean not apply to an own of property who Italian or improve desmon,and.
who contracts for such pea res,with a eontracems)licensed pursuant se the Communes
Lim.Law.
q
R lameaemptuMm Sum
e ,B&PCforthissson
Owner L_ Data
WORKERS COMPENSATION DECLARATION
t I hereby aRum under penalty of perjury one of the following dcelaratioor
t Nan and will maintain a Cmtifesm orc...i to self.i=m fm Wool compn-
sedon,u provided for by Section 5700 of use labor Code.for the Performance of she
wort for which this permit is Issued.
D 1 haw and will maintain Worker's Compeuadon InsWsnce.as required by Section
370D of se labor Coln,for an,performance ofthe work for which this pennft is issued. '
My Workers Compartment Insurance carrier and Policy number an:
carrier.. E/�4 Policy No.:
CERTIFICATE OF IXEMP170N FROM WORKERS
—. COMPENSATION INSURANCE
(This section need net be completed lithe permit is fer one hund.d Wines($100)
an teat)
1 ceury that in the performance of the were for which this pe ort Is Issued.I shall not
employ any person in any menncrwaW or�r4wb"a"10 the Workers'Compensation
Law,of CalifoJ/,vnnit�Dale 4
APPllanlLDA2
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject the the Workers Compensation provision,or the Jaber Code you an
O forthwith comply with pavbldor this permit l the Ecomed revoked.
yCONSTRUCTION LENDING AGENCY
' 1 he.hy aRrm sat the.it a cmtsuucdnn lending agency for the perrmace foof
.. the work for which dds permit is Wand(Sec.3097.Civ,C.)
E Lenders Name ,
Z Lender,Address
Q I certify,that I Mw rod this application and sue that We above information is
come"L 1.1.to comply with all city and county, mnces aNisad sou IoM muting to
Wilding eonwunion,and hereby wthorim representatives of this city to eater upon se
14abuw-mentioned Property fu impenlon purposes
06 (We)agma to an.indemnify and keep harmless due City of Cu ertico agaimt
IA Ilabilldv.fudgmcnu.now and expert..ss which may to any way a..aganst said City
In consequence of the gMting of this permiL %
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION
"t'//-0V Re-roofs
Stgnatum of App1.—VC-doctor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum building oacupant nom or handle hamrdov material
-
as defined by she Cupertino Municipal Code.Chapter 9.17-and the Health and Safety
Code.Scetien 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
DYu ®No
Will the applicant or future building oocupan(use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t ha'nNou air comaminmta at defend by the Bay Arca Air Quality Management all new materials for inspection.
Diauict7
DYcs MNo
I haw mad se harnduus mmedsis mquimnunu under Chapmr6.95 of 0e Califar-
nla Huls&SafmyCedc,Sammu25505.25533 arld 25531.1 undcmwd theiflM building
does not currently Mw a meant.that It b my amenability m notify de oseupent of d<
.gal.nentswnenrtmy aataa«af.Ccdhcdaofacepmry. Signature of Applicant Date
y-//-o6
Owner uauthorized agent DaeAll roof coverings to be Class "B"or better
'