07090054 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Vo._T ACTS INEURMA'TIO 1•
BUILDING ADDRESS: PERMIT NO.
10379 —Tf AR U A
OWNER'S NAME:
sWrftgy10.2 0 0 CONTROL NO.
10th
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
a o 0 0
Z LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U with Section 7000)of Division 3 of thc Business and Professions Code,and my license is
y in full force and effect- TEMP POWER
3? License Cla s Lic•8
Lu
Date Contractor BUS LICENSE PD TODAY FOR J.A. CHAVEZ $107 . 00
RCHITECTS DEC O
-� 1 understand my plans shall be used as public records
U _
F" Licensed Professional
a OWNER-BUILDER DECLARATION
^r
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
:110 following reason.(Section 7031.5,Business and Professions Code:Any city or county
Li which requires a permit to construct,alter,improve,demolish,or repair any structure
} prior to its issuance,also requires the applicant for such permit to file a signed statement Sq.Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
C - that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation, 37515046 . 0 0
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
hsve and will maintain a Certificate of Consent to self-insure for Worker's Compen-
on,as provided for by Section 3700 of the Labor Code.for the performance of the
ork for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier; Policy No.:
CERTIFICATE OF EXEMP'ITON FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner so as to become t t pensation
Laws of California.Date v
Applican
NOTICISA of ng this Cc cart of Exemption,you should
becomet w orker's Compensation prons of the Labor Code,you must
Oforthwily th such provisions or this permit shall be deemed revoked.
i
CONSTRUCTION LENDING AGENCY
r� 1 hereby affirm that there is p construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
r z Lender's Address
1 certify that I have read this application and state that the above information is
►+ correct 1 agree to comply with all city and county ordinances and state laws relating to
jCF.) building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,toss and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: l6
SOU GULAT70 S.
• Re-roofs
sip6jkurco AppltcanUContraclor Date
HType Of Roof
AZARDOUS ALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs:hall be inspected prior to any roofing material being installed.
❑Yeso
tu.building occupant use equipment or devices whichIf a roof iE installed without first obtaining an inspection,I agree to remove
Will the applicant or
tit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
1 have read the heard materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 anc125534.1 understand that if the building
docs not currently have a tenant that it is my responsibility to notify the occupant of the
requirementswh hmust beme norwissuancaofaCcnifcatcoroccupancy. Signature 3f Applicant Date
—
All roof coverings to be Class"B"or better
Own r authorized agent Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 37515046 .00
DATE ISSUED. . . . . . . : 09/11/2007
RECEIPT #. . . . . . . . . . BS000002605
REFERENCE ID # . . . : 07090054
SITE ADDRESS . . . . . : 10379 MENHART LN
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUFERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : ANH & DAO NGUYEN
ADDRESS . . . . . . . . . . : 10379 MENHART LN
CITY/STATE/ZIP . . . : CUFERTINO, CA 95014
RECEIVED FROM . . . . : JA CHAVEZ CONSTRUCT
CONTRACTOR . . . . . . . : TBE - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBE - TO BE DETERMINED
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BTEMP FLAT RATE 1. 00 62 .10 0. 00 62 .10 0. 00
BUSLIC FLAT RATE 1. 00 107 . 00 0. 00 107 .00 0. 00
EPERMITFEE FLAT RATE 1. 00 40.79 0. 00 40.79 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 209 . 89 0. 00 209 . 89 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 209 . 89 VISA
---------------
TOTAL RECEIPT 209 . 89
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
CITY OF C'UPERTINO
TEMP1 `r070700
CUPEkTINO PERMIT APPLI[CATION FORINT
APN# Date:
Building Address:
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wner's -N ne: Pho e#:
Contractor: Phone: License 9.- �
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Contact: Phone- Cupertino Business License#:
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Building Pe it Info:
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Coo-
Job Description:
Residential Commercial ❑
Cost of Projec
Qty. if
Ap licab e Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING