06050205 (2) CITY Or CUPERTINO
BUILDING DIVISIONPERMIT i..CONTRA.C,*' 'OR INFORMATTUN
94 aa�r : 'h* �. L7 tW �sx+se§ '
BUILDING ADDRESS: DONG NGUYEN PFRMITNG06050205
10540 CULBERTSON DR
OWNER'S NAME: PERMIT'ISSUE DATE
ilkDONG NGUYEN
E: SANITARY NO. CONTROL NO.
ARCHIIECT/ENGINEER: BUILDING PERMIT INFO
BELECT
O O PLUMB=1 [�
u o p LICENSED CONTRACTOR'S DECLARATION Job Description
�+ 1 hereby affirm Nu 1 Am licensed under provisions of Chapw m
9(cameoning
IN Section 70901 of Division 3 of the Busirw.,and predications Coda,and my license is
;15mmnromean ire 77 /,. 48 REVISION TO ORIGINAL PERMIT# 05110051
in o:mnCC1ea nusnor B4 STRUCTURAL REVISION GARAGE ONLY INCLUDE REVISED
AR H SDECLARATIDN STRUCTURAL CALCS .
Sy I understand my plane shall be used u public records
k C� Licensed Professional
`.a OWNER-BUILDER DECLARATION
I hereby a him that 1 am exempt from tion Contractor's License Law for the
`O O following reason.(Secdan 7031.5.Bud.and Professions Cot:My city or munty
which raquiror a permit an eonsuuct,alw.ImProw,demMlsh,or mpeir my moreture
:'A t<2
prior m its issuance.Alm requires the applicant for such permit to Ole A signed statement
< IhuheLLlicenseJpunumttothe provisiomofduct Contractor's UumanLaw(Chepter9 Sq.Ft. Floor Area Valuation
3 (commencing with Section 7000)or Division 3 or the Business and Professions Code)or $0Nat he LL exempt themfrom and the basis far to alleged exemption.Any violation Of
Section 7031.5 by any Applicator for a permit mbkcu W Applicants ro A civil penalty of APN Number Occupancy Type
eat more than Rw hundred dollars($509).
0 1,u awtw Ortna pmpmy.o my mpio r=with woes u datr cele eompeaadon,
will do than work and the munut,is ontinteaded mattered formic(Sm.7044,Business Required Inspections
and Pmfessions Code:The Commune,Licenses ree ns Law dot apply d an owner of q P
propenywho builds mimprowad oxen,andwho doessuchworkbhnsefl ,Waugh his
own employme,provided that such improwmmta tae notinanded oroEennt foals.IL
however,me building or Impmvemem LL said within am year afoompledon,the ownsr-
Aulldm will have de burden of proving that he did ret build Or Improv for purpose of
tale.).
0 I,As Owner of dm property am exclusively contracting with licensed conhaclms b
come=tht project(Sec.70".Business and Professions Cade:)Tlm Canmcmr's LF
cense Law does not apply m an owner of property who builds or improv theseon.and.
who cenmcu for such projects with a contractor(s)licensed personal in the Conrranots
Lie.Law.
0 lamuemplunderSee .Bg:PCfar Wertamn
Data
WORKER'S COMPENSATION DECLARATION
I hereby&Than under penalty,of perjury ma of flat following declaradow
0 1 have and will maintain a CeniOm"of Consent mselfdnmrt far WarkeYsGonpen-
sation,an provided far by Seetion 3700 of the Labor Code.for thA perfomtanm of the
work for which this pareft Is homed.
0 1 have and will maintain Worker's Compensation inmrance,as required by Section
371)Oo(the Labor Code,for the performance Ofthe wart for which this pennhis luumL '
MCa Wm '� eo n nn lnamncec` oliandc'No.nuAn
�6� 2-23
\'CEER.TIIFFIICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secdm need ret beeompleteA Urha permit Is farm hundred do0ara(gl09)
or Ins)
I cenify dal In the performance of the work far which dB permit Is issued.)shall not
employ any person in my mannerm An At become subject d the Warless'Compensation
Laws of CAlhfarola Dae
Applicant
NOTICE TO APPLICANT:IL alar making this Cenincem of Exemption,you should
became subject As the Worker's Compensation provisions of the Labe Code,you amu
.7 Z forthwith comply with such provisions At this permit"I be deemed.1sed.
OCONSTRUCTION LENDING AGENCY
(.v I hereby aRim don there is a construction lending agency far the penomuxa of
rL
the work far whim thLL Parnell R haued(Sec.3097,CN.C.)
W�Q Lender's Name
z Lender's Add.
U O 1 caufy that I Mw read this application and sats:that six show information LL
U,P comm I agree in comply with all city and county uMinances end sate lama mlaMg ro
�U building construction,and hereby authorise reprexenRuws of this city to enter upon the
[Iti ahovamcationed property for impecuon purposes
(We)agree m saw.indemnify and keep harmless de City of Cupertino sow,
f..a rrAA1 liabilities,judgments.tom and expenses which may in my way accme against aid CRY
U Z in consequence of the granting of this Parnell.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
LS
Signuurt of AppUoHAZARDOUS MATERIADISCLOSURE Data of Roof
Will the applicant or future building occupantseam or handle hazardous material
As dented by Use Cuptu no Municipal Code.Chapter 9.13,and the Health and Safety
oda,Seedon 25532(a)? —/ All roofs shall be inspected prior to any roofing material being installed.
❑Yes �O
Will the Applicmr or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir hervdaus air conuminsnts as canned by the Bay Arta Air Quality Managemem all new materials for inspection.
District? /
Oyu (QNu
I hon mad the herudsmmawWs requlmmcrosun@rCh,pw6.950fileCalifor-
niaHmlthkSafctyCO7e,Swd=25505.27533NW25534.lundervmd ifW Wilding
does not currently haw a tenant.the It R my ormonsihility,m notify the occupant of the
rtgvl nknmaubc IPoorIniaammaraurdTR,tearampmty. Signature of Applicant Date
u �a may( �( �'/!a/o All roof coverings to be Class"B"or better
Owner or authonued agent ' U Dore'