03030110 ;OOWNER
TY OF CUPE]ITINO ��^'
BUILDING DIVISION PERMIT 9W-WRACTORINFORM, QN 'lr
DING ADDRESS: PERMIT NO.
HIEN Q. TRUONG
S - FERMRES A
NE: - SANITARYN 0 OLNO.
ARCHI7EC IENOINEER: - BUILDING PERMIT INFO
8LDO ELECT
0
= O PLO O
1.0 - LICENSED CONTRACTOR'S DECLARATION
rely F I hereby AM.that l am licensed under previsions of Chapter 9(commencel Job Description
n)2 with Section 7000)of Dlvl.ioe 3.r the Bomb....I Pmfesalon Code,and my license la
<
in full to=and effect.
Ry.g License Cuts Uc.A TEMP POWER FINALE®
G W Date ContractorARCHITECTSLARATION
understand 1 understand my plana aNheUseDECLARATION
ll be used As public reenrds - MAR
slAs� gg
R 4 2003
`O Licensed Professional
OWNER-BUILDER DECLARATION
i0 I hereby.(firm on 11. exempt from the Cations Code:License Law for the ,
po followingdre.a (Sado.71131.5,Bu.1mr. and Pne,demlih,MAny ally,county
which mqulrcs a permit m cnnnmcl,cited Impmvc,demolish,err mpolr Any mmnure BUILDING
pd,to l6 issuance.0su requires the applicant forsueh permit m fde a signed MIDerml
< that he is Bmnred punuant ro the pmviscea of the Communes Licen,<Uw(Chaplm9 Sq. F[. Floor �I� ion
Cz� (commencing with Section 70DO)of Division 3 o the Buchroc rad Professions Code)or
3.. that he Is exempt Nemfrem and the basis for the alleged exemption.Any vlolauun of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of yam, Occupancy
not msec dun five hundred dollars(SSOO).m 3'WsPTdT@ Pf 00 Type
e - -
❑I,as owner of the property,,my employees with wages u their ole compensation,
will dal the work,and the structure Is not intended or offered for sale 7044,Business 103 - UFER
and Pmfmsiom Code:The Contractors Limine law don not apply toan owner of Required Inspections
property who builds orimpnows thomn.and who does auchwmthimselfor thmugh his 304 — ROUGH ELECTRICAL
own employee,provided that such improvements tie not intended oroffered for We.If,
however.the building or Improvement is sold within one you of completion,The owner- -
builder will have the burden of proving that he did not build or Improve for purpose of - -
sale,). ..
❑I,As owner of the property am exclusively contracting with licemed comnnnn M
consumer the project(See.7044,Business and Profession Code:)The Con racteri U.
come Law dou not apply to an owner of property who builds or improv themon,and,
who contracts for such projects with a contrutor(s)licensed pursuant to tie Contractors
License Law. -
❑I am exempt. der fee. .B&P Qfm this noon
Dun
K/ WORKER'S COMPENSATION D^ RATION
1 hereby AID=under penalty of perjury can o the following dmluationu - -
IhawandwillmaintainaCenlficam of Consent to scit.l.um for Worker's Compm. - - -
"unn,u Provided for by Section 3700 of the lab,Code,fee the performance of Be
work for which this permit is issued. '
❑I has and will maintain Workers Compensation Insunnm,As required by Section - -
3700ofThe Larm,Code,for the performance of the work fm which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am;
Carrier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not heeampleted if the permlt Is fortune hundred dollar($100)
I certify that in W)Ictim,marm of the work for which[his permit Is issued,I shall not
employ any person insinVerunceran As to become subject to the Workers'Oompewtion .
Laws of Califoch.. a
Applicant
NOTIC F APPLICANT.If.After making this Certificate of Exemption,you should -
hecom bject to the Worker's Compensation previsions of Bre tabor Code.you most -
,'O forthwith comply with such provi dons or this permit shall W deemed revoked. -
,z.m r"m CONSTRUCTION LENDING AGENCY "
F I hereby arum that then Is a construction lending agency for do lerf.nnems of
a?,v
the work for which this permit h issued(Sm.3097,Civ.CJ
WM Q Lenders Name
� z Lenders Address
t.)Q I certify that 1 have mad this application and Mate that the above information is
Iy F correct.l agree to comply with all city and coumy ordinances and atste laws mlaung to
O V building construction.and hereby authorise represanmiv of this city to enter upon the
If] shave-mentloned property for inpccuo r purposes.
(We)agree In save,indemnify and beep numbers the City of Cupertino against �j
f..i fA Habilltes,judgments,costs and expenses which may in any way ucn,agarol old City
U in consequence of the granting of this permit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: f
Date
SCOU,�CE REQULATIONS. �,, ��
�" ,It_U !4!4 _ %2.�f 7 Re-roofs
Signature of Applica.1 contncmr Dae -
HAZARDOUS MATERIALS DISCLOSURE - Type Of Roof „
Will the applies.[Or future Wilding occupant Alone or handle hayardous material
a dcOncE by the Cupertino Muni trial Code,Chapter 9.12 and the Health and Safety
Code,s yrs zss3z(.17 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant of future building occupant use equipment or devlms which If a roof is installed without first obtaining an inspection,I agree to remove
it hemobus.1...taminants defined by the Bry Arca Air Quality Management all new materials for inspection.
busier? /,as C3 Yes �No
Ihave mW the huardous materials requirements under Chapter 6.95 of Be Cairo,
nia Health&SafelyCodc,Sections 25505,75533 and 35534.1 undenund that lithe building
does not currently has a tenant,that It is my msponalhllity a not l'y the occupml M the
cqutrc nuwhichmustbemetimortoiuuanccnfaCcnj(u o u er. Signature of Applicant Date
A wncr,auuodxed agent3 g D„e - All roof coverings to be Class"B”or better' -