04040189 CITY OF CUPERTINO >p♦(s < it pan
BUILDING DIVISION PERMIT 'I\�0NsTA•�a•70011 �s
BUILDING ADDRESS: T I EP D. NGUYEN PERMITNOs 4 04 018 9
'�2r:70 SAN JUAN IRID
OWNER'S NAME: PERMn ISSUEDATE
TRP T) . WITIYEN ncz1r)71,)o -
4
SANITARY NO. CONTROL NO.
(408) 972-2575
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Y O O LICENSED CONTRACTOR'S DECLARATION
1 hareby affirm that 1 am Restated under prevision of chapter 9(commencing lob Description
with Section 7010)of Division 3 of to Business and Profession Code,and my license is
a � in runmreeaoderrea`
LREVISION--IN HOUSE USE ONLY
j Z kense Class Lic.#
a Dam Connector NO NEW PERMIT ISSUED/ORIG. #04020072
Is4 ARCHITECTS DECLARATION
a< 1 u mormi d my plans shall W used a public meads
Jeu
#,8t; Licensed Professional e
3 OWNER-BUILDERDECLARATIONCe ContrON
I hereby amrm that I R-exempt from the RATION Lkenm Lew for IW
OO following moron.(Section 7031.5,Business and Profession Cade:Any city or county
B which requires a Permit In construct,alter,improve,demolish,or repair any someone
_Z to prior to its issuance,also mquims the applicant for such radefuo role a signed statement
pF G that he is licensed pursuant to the provisions of theConlrsemer icenseLaw(Chapter 9 Sq.Ft.Floor Area anon 0
yF (commencing with Section 7000)of Division 3 of the Business and Prafessinns Cadej ser
RN$ Nal he is except Ihemfrom and the basis far Ne alleged cacmpdon.Any=of
Semon 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
noAPN Number Occupancy t more then five hundred dollars(M). P y •J pe
❑I,as owner office property,or my employcu with wages as their sole compensation, 34218020 . 00
will do Lha work,end dissociation is not intended oroffereA for sale(Sec.7061,Business
and Profession Cod.:The Com ortures Licence Law does not apply In an owner of Required Inspections
property who builds or improve dtercon.and who does s uch work himself or through his
own employa.a.provided thatsuch improvement,are not Intended at offered formic.If,
however.the building or improvement is mid within one year of completion,Ne owner.
builder will have the burden or preving that he did not build or improve for purpose of
sale,).
I.es cru.of Om property,am exclusively committing with licensed contractors to
nswcl the project(Sec.7016,Business and Professions Code:)The Constar's LF
cense Law does not apply to an owner of property,who Wilds or impmvm thereon,and
who Contracts for such project with a condactor(s)licensed pursuant in the ConuadoYa
License Law.
❑tun tie pt under Sec. B&PCf�Ni �aaon
Ow Date S , JTL
WORKER"CO PENSAn ^DECLARATION
I hereby alTmm under penny of perjury c of the 1.110 Ee coons:
haw and will maintain.CenlOum ofConsenua self-Insure for Wadi Comfort-
soup.as provided for by Section 3700 of the Labor Code,for the perfurmmu of the
work for which this parrs t is mood.
❑1 have and will maintain Worker(Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is Issued.
My Workers Compensedon less...carrier and Policy number art:
Caner. Policy No.:
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
fnissection need not he completed Base permit Hfarane hundred dollars(SIM)
or less.)
I oadfy that in the performance of Use work for which this Permit is Wood.I shall not
employ any person in any mannerso m to Wcomc subject o the Workeri Compensation
Laws ofCalifornia.Dam ,
Applicant
NOTICE TO APPLICANT:If,after making this Cenifinm of Exemption,you should
become subject in the Workers Compensation provision of On Labor Cade,you must
.JO ronlewiN su
comply with ch provisions or this permd
iuhill W deemed revoke
.Zi CONSTRUCTION LENDING AGENCY
[—t I hereby affirm Nal then is a canuactinn lending agency for the performance of
the work for which this permit is issued(Sec.3M,Civ.C.)
Q lenders Name
z Lenders Addrus
J 0 1 certify that I have read this application antl sate that the above information is
LT.F correct.I agree to comply with all city and county ordinances and stale laws piloting in
C V Wilding construction,and hereby auderim represcnativu of this city to crime upon the
W above-me a)mialagar to ertysave for hammunry an keep hs.
gyp (We)again I,mw,intic expenses
and kith hay in an the y as of Cutins,against
rayZ liabilities,encs o Be granting
aintl cxpeascemit. rosy in any wayscene egeinnmil City
U z APPLI ANT of UNDERSTANDS
of this permit.
"^ APPLICANT UNDERSTANDS AND WILL COMP4Y WITH�L NON-POINT Issued by: Date
gOy$CgREGr�LATyION, M^ , .� /'Id Re-roofs
mature(of4p~plliionnt/c.ntn�a or l/t/L� "yy// Doow'I
HAZARD USM RIALS DISCLOSURE Type of Roof
Will theapplicam or fumreb Tiding occupant uorc or handle hazardous materiel
as thermal by the Cupertino Mudal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yo Nu
IWill the applicant of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous it,conaminenu it It by the Bay Aro.Air Outlisy M...ganum all new materials for inspection.
District? `3m/
❑Yes Nu
1 have mail Ne hmardousmamrials mquimmen6 under Chapter 6.95 of the Celifor.
nia Hnith&Safely Colo Sccdons25505,25533ud25536.lun&m=dthatif On Wilding
Jou not currently haw a mmol.that It u my national dry the oecapnl of Be
reyvi wh h Z, srbe IpbrmBsu e.facenifiaano rOcea ncy. Signature of Applicant Date
t� Ole
OwnermauthrizcJagent I Dam All roof coverings to be Class"B"or better