06070052 CITY OF CUPERTINO x tyw•u �° n , „�.`,'
BUILDING DIVISION PERMIT 'WCONTRA0j0R4NFORMATION�
BUILDING ADDRESS: , PERMIT N006070052
192-41 PHIL LN
OWNER'S NAME: PERMIT ISSUE DATE
VAN TRAN
E: SANITARY NO. CONTROL NO.
ARCHTECTIENGINEER: BUILDING PERMIT INFO
BLDG Et•ECr PLUMB MECH
sura LICENSED CONTRACTORS DECLARATION - IOb Description
ns I hereby affirm that 1 an licensed under provisions of Chapter 9(commencing P
!Zo, with Section 70W)of Division 3 ofdrc Business and Professions Code.and my license is
�„ in full(arcmdeffett 2 Z REVISION - RETROFIT .FOOTING
,q? Ll"nmcl Carat ORIGINAL PERMIT #06020137 NO NEW PERMIT
•Fp Dem 'i Conurcmr
/1ARCIUTECfS DECLARATION
i m i 1 undersand my plans shun W used Is public records
i ul
o Licensed Pmfcssional
3 OWNER-BUILDER DECLARATION
E 1 hereby affirm that 1 am exempt from the Conaamar's License Law for me
:C O following mason.(Sccoun 703 1.5,Business and ProfaNuns Code:Any city or county
which requires a permit to co mats,ales•+,improsc,demolish,car mpair any structure
to prior to its icsumeo.also requires the applicant for mach permit to file a signed so mmcns
Valuation $O
that he is licensed pursuant the provisions of me Contractor's License Law(Chapter 9 Sq.Ft. Floor Area
ex
`h$ (commencing with Section 7")of Division 3 of JO Business and Prefessians Code)or
-- that he u eacmpt therefrom and the buffs for the alleged exemption.Any violation of
Section 703 L5 by my applicant for a permit subjects the applicanuo a civil penalty of APN Number Occupancy Type
not more than five hundred dollar(SSW). 37540047 . 00
1,u owner of tie property,or my employees with wages Is then sole compenudon,
will do the work and the swcmrt is Out intended or offered for sale(Sec.7014,Business
and Professions Cade:The Coomcmis Liana¢Law does ml apply in m owner of Required Inspections
property who buldingoloh;ormpro sment is and who ithin one
Year orkhimaelf o.through has \
own employers,provided Not such improvements are not intended reoffered for are.If. -
b0der,the Wil dingbrImprovementu sold withinone year or i.p.feemeowmr-
builderwill have Ja buten of paving Nal he did Out Wild m improve(or purpose of
Salc.l. /P
❑1,as muter of me property,am exclusively ci n moving with licensed mnuxmrs to
construct the projca(Sec.7014.Business and Professions Cade:)The ConUacmts U.
come law does oat apply to an owner of property who Wilds or improve thereon,and
who contracts for such projects with a contractor(s)licensed pursuant in the Comeaemr's
License taw.
rl 1 am exempt under See. .B Q P C for this ma.on
Owner Data v\
WORKER'S COMPENSATION DECLARATION
Wh1 hereby affirmaffirmne under penalty of perjury oof me following doelara Irma,
In and will maintain a Certificate of Consent self-insure for Workers Compen-
smian,u previded for by Section 3700 of the Lahor Code.for the performance of the
work for which this permit u caused.
[_)I have and will maintain Workers Compensation Insurance,as mquircd by Second
3700af me Jaber Code,for the peffomance of the work for which this permit is issued '
My Worker's CompenaJon Insunn z camas and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiasectim need net becomplowd if the permit Is forone hundred dollars($100)
or nus)
1 lenity,met in the perfomanec of me work for which Nis permit is iaucd,label not
employ any permn in any mmrterm u in hccomc mbjca m JC Wmkcrs Corm,maeoon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject On me Worker's Compensation provisions of the tabor Code,you mesa
,J O foMwith comply with men provisions or this pmer l shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-+ I hereby aRrm that more is a concoction lending agency for the performance of
LYi > me work for which this permit is Wind(Sec.307,Civ.C.)
1 Q Lender's Name
Q z Lender's Address
U Q 1 ccnify that 1 have read this application and state mat me above information u
UL corrin I agree to comply with all city"county onlinanm am sum laws totaling or
QU building construction.and hereby authome mpreacmativcsof this city to enter upon the
.1W c.mcnooned properly for inspcmon pugwacs.
(We).gree to arc,indemnify and keep harmless tic City of Cupertino against
,Far In liabilities,judgments.coda and expenses which may in any way acme against aid City �� L
t.)Z in consequence of the granting of this permit
^ APPLICANT UNDERSTAND N -WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
�> �® Re-roofs
sie9a7q rA"I on
Date
H RDOUSMATERIALSDISCLOSURE Type of Roof
Will the applicant or future building acupanlstorc or handle huvdous material
as dericed by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
code,Seeam 26532(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑6'cs VG -
Will Jo applicmt or future Wilding oavpant este equipment or devices which If a roof is installed without first obtaining an inspection,l agree to remove
t handous air contaminants as defend by the Bay Area Air Quality Managcmcnl all new materials for inspection.
oit ie,?
❑Y ,\\LLLLLLNu
es LB
1 have mal me hvaNummIwd.lr requirements un,der Chapter 6.95 ofthe Cali(.,
nim HcalmksafetyCodc,Seetiom2550,y
currently255JJ am125534.1 undersand Nttif me Wilding
dotot currently ham u tenant pons
mndtil'y Jx "cup fthc
reyulrcmcnts wh iib dor nnaaanm ccuroam car wro Signature of Applicant Date
Owne, mar;. age Z All roof coverings to be Class 'B"or better