06040042 CITY OF CUPERTINO
'BUILDING DIVISION PERMIT V'0 RA0,TT91t,INIF,(IR,MMIONr,
BUILDING ADDRESS: ACME & SONS SANITATION/ELE TMING06040042
21150 HAZELBROOK DR
OWNER'S NAME: PERMIT ISSUE DATE
ANDREW KHA NGUYEN & MINH D VU3408 HILLCAP AVE 04/10/2006
ONE: SANITARY NO. CONTROL NO.
(408) 295-2263
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BO EQ PLUMB MEOCH
lop LICENSED CONTRACTORS DECLARATION
I I hereby am.Nal 1 w Ikmased under provision of Chimer 9(commencing Job Description
methIlf..srd aLiviaion Jof the Buunaa and Profusion Cade.aMmyliamnu pj_� �
+❑ himumreeandercecc INSTALLING TEMPOR ®]/••]
> :_ Lianan c ssa Lk.. R�3 S_ 3
Deo; _Lw#ckr EiSetVf h6[TR rL
J ARCHITECTS DECLARATION
f I understand my plans shall be used as public records /P
rets5 Licensed Pmfessi...I
50] OWNER-BUILDER DECLARATION
m
a7i 1 hemhY atBnn that 1 em et from dm Contractor's Licence law for Nm
p O following reason.(Saban 71131.3,Bust.and Rafuu.m Code:Any they or aunty
5$ which requires a permit be conaact,stem.emprow.demolish,or mime,any structure
$100
ZSn prior to its issuance,also require dm applicant for such per-rail to rile a signed su¢mem
G that he is licensed pursuant to the provision of the0004Clar'sIJccneLaw(Chapter 9 Sq.Ft. Floor Area VW Valuation
$ (commencing with Scedon70(0)af DivitionJafdu Buumasand Profeveon Cade)or
Net he 4 mempl therefrom and the basis Re Ne alleged eaanpdon Any Noladon of
Settle.7031.5 by toy applicant m applicant fa a pelt subjects the applict a rnU penalty of er U Occupancy Type
ype
not mom than fin hundred dollars($500).
1,ss awrwj of the prape,ry.a my employeos with wgo u trek role ampensathon,
wiBdothecomic-and Wenmmum6nminundedmorrr Tressle(Sa.7044,Busircss
and pmfessian Cade:The Conuacmra License law does ant apply u an awrer of Required Inspections
pmpeny who buildsorimprons thereon,andwho doesswh work himselfmthreugh his
awnemplayam.provided Out such imp or mass are,notim muked uroffmad fossole.It.
hwrcsv.the building Or empmvemem ts sold within orc year afampkda.the ownu-
builder will haw thea burden of pmHng that he did new build a improve far purpose of
sale.). r
0 1,as mvnr of the property,am exduunly communing with Naaaed anuacmn u
construes the pmlem(Sec.7044,Business and Prafetuan Cade:)The Conuseae,U.
came law dors not apply m an awrer of property who builds or improves themes.and,
who contracts for such pmjecu with a contractor(s)licenced pursuant to the Conuacmr's
Licence law.
0 lamaaemptunda See .B&PCfxs1fix e
Owner Dau
WORKER'S COMPENSATION DECLARATION
41 I hereby minim under penalty of perjury new of the following deeluatimrs
0 l haw and will maintain aCemelkam of Consent to self-imam fa Workds Compen.
anion,as provided for by Season 3700 of the labor Code,for the performance of the
work for which this permit is issued.
0 1 haw end will maintain Worker's Compensation Irwrana,as required by Section
37M of the labor Code,for the performamof da work for which Nes permit is issued.
My Worker's ComA{pemuton Insam nce tamer and Policy number ace:
Cartier N/7 Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ThuseNon reed not he completed NOW peals or forma hundred dollar($I00)
or leas)
1 artily Net u the performance of the work for which this Permit ts issued,l Nail am
employ any pawn In any mane`an u m become subject m the Workcri Co,npenedon
Law of California Dam u—r. –0&
Appal I RAL "77)rr 11""De 3. ta:L.
NOTICE TO APPLICANT:If..Rer making this Cenelkau of Exemption,you should
become subjm m the Worker's Compensation provWmm of Ne labor Cade.you mus
vJ O forthwith comply with each provisions or this permit shall he damW reolmd.
'Z►
CONSTRUCTION LENDING AGENCY
j–r I hereby affirm that Nam is a eorumcdnn lending agency far the polimmenm of
ani the work for which this permit ts Issued(See.3097,Cin C.)
W�0 lender's Name
z lender's Address
U Q I cannily that I ban rad this application W sum that thea also.Informed..Is
IL f~ comem l agree in comply with all city and county ordinances and mom laws relating 1. ,
DU building construction,and hereby authorize represenuti.s of this city to enter upnr the
117 above-mortared pmpeny for inspection pugmses
(We)agree to sow,indemnify and kap ammkss the City of Cupertino against
,,7 liabilities,judgments,coats and expenses which may in any way we= SaImt said City
U,Z en canmquenee of da granting of this Permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE ONS.
°/-119-02/< Re-roofs
Sigwurt of Appllunt/Camrsetar Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIN the applicam or farm building occupant sum or handle haeardom maariu
as deRned by the Cupertino Municipal Cade.Chapter 9.13.and the Health and Safety
Cade,Sadon 25532(07 All roofs shall be inspected prior to any roofing material being Installed.0Ya XNo
Will the applicant or forum building eaupant use equipment ar deVlaa which If a roof is installed without first obtaining an inspection,I agree to remove
emit haardnns air eanumenanu IS dented by the Bay Area Air Quality MamQenienl all new materials for inspection.
Disuect7
Oyer 1§Nu
I haw mal the hasenlam materials requirements undcrChapkr6.95 of the Califor.
nu Health&Safety Cade,Scerlens 25505.25537 and 25534.1 understand the lfthe building `
does at currently haw a mnsm thss it h my responsibility he rrni(y the occupant of Me
requireum 6c met priarm issuance or.Cmulksw of Occupancy. Signature.of Applicant Date
+ —/0--O(o
Owner orauthomcdagent Dam All roof coverings to be Class"B"or better
CITY OF CUPERTINO
Oem 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32655027 . 00
DATE ISSUED. . . . . . . : 04/10/2006
RECEIPT # . . . . . . . . . : 33896
REFERENCE ID # . . . : 06040042
SITE ADDRESS . . . . . : 21150 HAZELBROOK DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ANDREW KHA NGUYEN & MINH D. VU
ADDRESS . . . . . . . . . . : ,
CITY/STATE/ZIP : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DANG NGUYEN
CONTRACTOR . . . . . . . : ACME & SONS LIC # 21563
COMPANY . . . . . . . . . . : ACMF & SONS- SANITATION/ELECTRI
ADDRESS . . . . . . . . . . : 3408 HILLCAP AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95136
TELEPHONE . . . . . . . . : (408) 295-2263
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BTEMP FLAT RATE 1 . 00 62 . 10 0 . 00 62 . 10 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT ,: 100 .47 0 . 00 100 .47 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 100 .47 AMEX
TOTAL RECEIPT 100 .47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
•
Community Development
10300 Torre Avenue
µ Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
@CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
Z115-0 NA�Ec Bt< D i✓E
OWNERS NAME:ANDREW K04 14&vYeN¢ MANN blew V U PHONE # (4v$) &920-2-36-5-
GENERAL
829-2305"GENERAL CONTRACTOR: RegL am-rr &„co x,.(c. FAX # (40x)
2.5+2 - R 3°l 2-
I
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical GME 9- -504) KT?- C, 2 Seo 3
Excavation ---
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile .
Owner/Contractor Signature Date
CITY OF CUPERTINO (v)
TEMP POWER
• CUPE OF PERMIT APPLICATION FORM
APN # 32t0 5 '7 Dat
Building Address:
2-11- O HA ELBRvoK "DA IV67 _
Owner's Name: Phone#:
AN,-bQt=ww Kqq PJ( vYer/ 4- M/NH Dr Eu ' VU (40 2;)?A20*34059F
Contractor: De vi S&/, s OF u w i� sM2,75-+.us Phone: 2 - Z2 4O 3 License #:
ca z v c
AGMC 4 SOw$ 'ccecrcF-73 SS- 3
Contact: Phone: Cupertino Business License#:
>At4 (r NCtvy&N � ybg �2a( -2gbS- IrJ
Building Permit Info:1n1 }tea( n 'jC? .� 100L- W fo LS1-
Elect 2-
Job Description',
Residential Eg— Commercial ❑
u8 'Ilcr .
Cost of Project: �-
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
•