05070045 CITY OF CUPERTINO a - - �'•'
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION.
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BUILDINGADDRESS: M—TRAN CONSTRUCTION, INC PERMIT NO.O 5070045
OWNER'S NAME: PERMIT I SUE DATE
PHAN CANH
SANITARY NO. CONTROL NO.
650) 996-6099
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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o0o _LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am licensed under prevision of Chapter 9(commencing p
�to with section 9rl(IU)ofDivision 3orthe Bus;nest and Profession code,and my license is
m fret ar if r�.-g20587 HOUSE DEMOLITION
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Zip Dau: Contractor AIyl}A.J
ARCHITECTS DECLARATION
l a< 1 mccound my plans shall M used as public records
ZyU
aQhs Licensed Professional
OWNER BUILexempt
m the CommON
encer
.�0 0 I mase affirm on 1 am exempt from the Conine Cod :Anyc Law(of the
p o followingmason.a (Sedan 703 1.5,Business and improve.
do ions h.or Any oily or county
m which requires a permit m conawcL elmq improve.Jcmelksh.or repair any swnum $4000
prior in its issuance.also requires the appllesom for such permit to Glc a signed summent
tb<
that he is licensed puuuanuotheprovisions ofNeContractor's limncLaw tChapar9 Sq. Ft. Floor Area Valuation
¢�$ (commencing with Section 90(0)of Division 3 of the Business and Profession&Code)or
— Net 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 m five hundred dollars(55(103. r Occupancy Type
th
El 1,as owner arshe propeny,a my employees with wages as their sole compensation,
will do Ne work and Ne awcwa is ms intended a pffemd Russia,(Sec.?)44,Business
and Profession Cade:The Conumtors License law does Out apply in in owner of Required Inspections
progeny who builds or improves thereon,and who docs such work himself or through his .
Own employca,provided that such improvements tie not invmded or offered forsalc.If.
however.he building or improvement is sold within one Seo of completion.the owner-
builder will have the burden of proving that le,did not build or improve for purpose of
rale.).
❑1, r owner ori the property,,B sines and contracting with licensed contractors to S
cc=La Ne project(Sec.o in Business and Profeatloes Cade:)The Conuactols and. ���
cease law dos not apply e is owner of progeny who builds or improves so es thtsmen,and
whonse Lo u for such pmjeeu with a eanwnor(s)licensed pursuant m the ContrumYs
License Law.
❑1 am exempt under Sec. .B&P C for this resson � C
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following hclantions:
1homn.as and will mad nuineCcmn3am of Cm Labor Code.
a Wmkctsce of the
seinen., provided for by Section 39IXI of Ne labor Cw4,far use performance of the
work for which this permit is issued. 'S
❑ I bow and will maintain Worker's Compensation homm nce,as requited by Section
My We Ne labor Cwe,for Ne peRor emee of d wort mmd,ech Nu permit is issued. V/�.�
My Worker' Comyp�ensation lnsu�rasnce artier and Policy numMr are: _ �p
Carrier. �tfJl ��Pp Polity No.: I7SO2SS/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuction need not he completed trusts permit is intone hundred dollars($100)
or less.)
1 cenifv Net in use Performance of the work for which this permit is issued.I shall not
employ any person in my manner in as an become subjecOo the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.Jz forthwith comply with such provinces or this permitahall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
Pr�-v Ihereby affirm that lbere is a mnwctinn lending agency for the performance of
W > the work for which this permit u issued(Sec.30'I],Civ.C.)
If]0 Lander.Name
gL Lender's Address
az
U O 1 coolly Nat I have read this application and stats that one above information is
D.F correct.l agree to comply with all city and county ordinances and sum laws missing to
0U building construction.and hereby authome representatives or this city to amour upon thc
fJ above mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harts less the City or Cupertino against
g�q
Liabilities.judgments,costs and a.,.,which may in my way accnm&gat., to City
U z to consequence of the grouting of this Permit. A--
APPLICANT UNDER AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULA
Re-roofs
Signature of ApplieanUConuaetor Dan
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hmvdous material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Heald and Safety
Cook,section 255320)?ED Yes AN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupier use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hXOmbms air commonanu as de0ned by thc Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes AN.
1 have mal the hararmus materials rogWmmems under Chapter 6.95 of thc Califon
nice Hcelds&Salla,Code,Section 25505,35533 and 25534.1 undcrsund hat due building
does nut can tly ha nanL Nat it u my ruponibilisY to notify the acupmt Of dm
myuimmonts vd, _Ores priofmlvuanccora Cerdfieau of a ey. Signature of Applicant Date
SMO_
Owner or authori,ld agent — Dam All roof coverings to be Class "B" or better