06110139 (2) CITY OF CUPERTINO k 14 f " °
BUILDING DIVISION PERMIT _ICOk fItkC' O,T iRORMATION
BUILDING ADDRESS: PERMIT NO.06110139
10540 CULBERTSON DR
OWNERS NAME: PERMIT ISSUE DATE
DONG NGUYEN 19 /1 -4 /2006
NE: SANTTARY NO. CONTROL NO.
ARCHI'IECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
fop LICENSED CONTRACTOR'S DECLARATION lob Description
i U Jam I hereby afBon ul I Recreantunder Provfdmu or Clupur 9(commencing p
with Section 70M)of Division J ofthe Buirwns and Pra(assian Codc.end my license is
r�o in full fares andcffen REVISION: VENTILATION HOLES AFFECTING STRUCTURA
i'�' ? License Class Lie.a
f,o Dau Contraam BEAMS .
ASDECLRATON
IutlersunJ myplasslat ORIGINAL PERMIT: 05110051
c
)yU
C Clewed Pmfcssional
OWNER-BUILDER DECLARATION
n o 1 hereby.(Sect Not 11. nud from the Cation. rs s!Any
Law for Nc
❑O following mason.(Scotian R13 L5,Bu.Uncss and Imitation.der .ll Code:Any city or county
f m'a which requires n permit re cmtsnc,aper.In for such
h pcmit t fi c a sit any asoulommum
Prior m its tensed e,ilea requires No applicant far such perm"'m file se,Law etaumem
?C
he,beingwdpuntion7(10(cpmvisionso of
dPrafkadonChopmr9 Sq. Ft. Floor Area Valuation
��$ (commencing with Section]000)o(Divuion5nf use Business ad Profession Code)or $461800
_ Na'he is eumpt therefrom and the basis for the alleged nempdon.Any violation of
Section 7031.5 by any applicutt for a permit subjects the applicant to a civil initially of APN Number Oeeu ane e
not mom Nan five hundred dollars($300).
P Y�YP
❑I.uwxr of NC Progeny,ar my empbyw with waguasthe'v cola eamprnuJan,
willdo Newortandthesnaumuw'InuM dmoffe foraale(SIL.]W4,Badness
and Proreasi..s Code:The Commutes Liaeme Law door at apply to an owtrer of Required Inspections
propeny who builds or improves thercon,and who doessuch work himulfor through his
own employ¢s.provided Nal such improtemenu are not in¢Mr9 or offered for tile.IL
however.Ne building at improvement Is aid within one year of completion,the awnco-
builder will have Ne hurtle.of proving Na'he did not build at improve far purpose of
.Is.).).
E3 1,/u wrcr of this,Property as a icludvelY crimsoning with licensed conuonma to
connc'the project(Sec.7044.Business and Profusion Code:)The Commencer Li-
cense law doss not apply Io an Owner of progeny who builds or improves thamr,ad
who contracts for such projects with a eonamcmds)licensed pursdnt in Ne Convenor's
License Taw.
❑lame sunder Sec .B&Pcforthisreaun
Owner Dam 12 fl o
WORKER'S COMPENS TION DECLARATION ,
1 hereby aRnn under penalty.f per' ry tine of ate following declaration:
have and will md.uin sCanifsom.r Cmoem m selfAn um for WorkersComem-
on,as provided fm by Section 3700 or the Labor Code.for Ne performance or the
work for which this permit is issued.
❑1 have and will maintain Worker's CompsmationInsurance,as royuired by Section
3700o(Jc labor Code,far Ne pcdormance oflhe work for which this permi'uWood, '
My Workers Compewuon Ilion a ea Tier rad Policy,number are:
Cartier: Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Thus section need not M completed if the Permit is for ane hundred dollar(SIM)
or less)
I catifv that in Ne performance of the work for which this permit u issued,I shall nm
employ anyperson in any manners.as to bac sYbJeIct-M}1 kora Compensation
Laws of Califomia.Disc - e t� L 1 o f-�
Applicant _O le N P
NOTICE TO APPLICANT:If.after making u Ccnifiatc of Exemption,you should
become subject to he Workeh Compcnsnio provisions or the labor Codc.you must
.J O forthwith comply with suds pmvisinn or N Permit shall be domed rtvoked.
CONSTRUCTION LENDING AGENCY
[-� r I homey affirm that Nem is a coulmetion
rL ti lending for the Te
rformamc of
Ne work for which this mis Issued s .50],civ.c.)
W�0 atics Nam.
LM
a Z Latices Aaartn
U Q 1 certify Out I have=it this application and sum that the above Information it
Fcava'.1 agree no comply with all city and county Ordinances and stale laws relating to
0U building construction,and hereby authorim mpmunutives of this city to enter upon the
H 0. alrove-memiuned property for inspection purposes.
(We)agree Io save,indemnity and keep harmless Ne City of Caption.against
N liabiliues,judgmcnu,costs and expcnsas which may in any way accrue against said Ciny
U Z in cmisaimme of Ne granting of this Perini,
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEBEEGULATIONS,
srgn.ts umOfApppuara�a [L!pak_ Re-roofs
=R�S MATERIALS DISCLOSURE Type of Roof
Will Nc applicam or fuwm building Occup intsume or hanNc hvvtlon maudal
as defined by the Cupenium Municipal Code.Ampler 9.13.and Be,HW N and Safely,
cotle.Section 25533(a)]Ya UA. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building occupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
i'h.ohou air conuminanu u defixd by the Bay Area Air Quality Management all new materials for inspection.
-ick
❑Yes �Nu
1 have real Ne toosmawxmamdais requimments under Chapter 6.95 of the Califon
ria Health&Safety Code,Secuou 35505.35577 and 25534.1 umlerstaM Nat i(the building
docs nal currcnJy ham a linen,that it u my a sp.mibilily m notify the,occupant of the
requirements which be melPrior wiasaancc ors emiratale.iaL poky. Signature of Applicant Date
ry1LI v6
Owner or aurhorb I agent a Dare All roof coverings to be Class .B.,or better