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CITY OF CUPERTINO x
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CONTRACTOR INFORMATION
BUILDING DIVISION PERMIT
y1;1ttW �rSA:n `fr'la m3eb` sY'vF3t3 .d :°:- r_
BUILDING ADDRESS:
PERMM NO.0 6 0 2 017 0
19741 BIXBY DR
'R'S NAME:
PERMIT ISSUE DATE
YVONNE NGO VAN
02/28/2006
ONE
SANITARY NO. CONTROL No.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
p
I lerebY tril. drat I w lice ucd ondcr pavlsfms of Chap ' 9 (..rcIttg
MN Secdon TOW) aDlWaion 3 a( de Boettua and Protetd«u Code. end my Nemec it
in full fame.ndeff«
REMODEL, MINOR STRUCTRUE,
Lk`n`°"'
REPLACE WINDOWS, FURNCE, WH, A/C
Corte
Dav; CantDEC
ARCHEI E
. Public d,
I uttdervanJ my pWs shall be tied u public gored.
LI d Pruf...1
OWNER -BUILDER DECLARATION
I bereby .term Nu I am eacMp, it. IM CmtcatWs Liaue W for the
f.Ilnoring tmmn. (Salon 7031.5, Buioeu end Pto(rui«n Cade: My city u county
which rtquirn a'emit In conneua. alwr, improve, dvndtW, or ccpalr any nrvtlare
pd«b iB W ua«c, oleo rcquhoa the applicant for wch'omit to Bd a slgnN tcucrucm
ilinn<afNoCa«r
Sq. Ft. Floor Area
Valuation
Natki:Remuedpaun;uwtaftMc -*-LH-ourol.w(Ch,ry«9
(ammtcrcin6 MN Secoon 701 a( DrMvun 3 a u1n, Budnm W Prcfc a. Cock) «
$550000
do, M b comp doMf. W tit ban f« Ne allrged ue.pd. My riot on of
APN Number
Occup y Type
Swdm M31.5byatry appWanl for a'ecoid wbj«u ds AWkant b a civil MuLhy of
wt on. than fns butWrtd doldn ($5001.
.
❑ I. u oww of the propary, «my wpfoym MN •+gc+a thele soy cmpcuulaa369199
- Required Inspections /
q pe
MR do Ne vah. and the atnm. dcot lmwded« aReted r«u5e (Sr�TON, Bonn—
Tyro Cacmts Ix o,, Law Joos cot apply ben Dome of
and Pmtesdau Code Thmlc
propwy donauchwrk «NrmN hie
«Imlm Mhiro
mortis n ded oror f«cafe If,
Dorn emplvyru,pmvlded Na such imp road a
'Pro
thrneot, MPl6bbE
bofl c vNetsovot butmr iiofFormtu sok Mdnoor Year o(iror l In, Ili
ynrrcnof
vender MB h.ve da: wtam or pm.;ng wt h< ala � daa «Imprme r« wm� or
«< /
tile.).
I,u a(Ik vwJy Prolactin{ MN:)The contcammeb
///
caoRrvct de pmjen (Sa. )01a, Bualneo W Rotntims Code:) The Cmmcmre u.
I unt Smpr.P7Y.04wuiti.
coase law dont n.l apply b co ower of popenY.Mn duke «ImpcoKa Ncrton. W .
.
who ®taacu f« such fwfene MN • convat«(s) Ilmtrtd purewu b tie Conuacta(a
LF...e IJw.
� 1 am racmq Mn Sec . B e P_C f« iEls rnsm
D.
WORKERS OMP ,710N DECLARATION
(u
1 hertbY.film tndec penally of'colo' ore a Ifs following do dntkcu,
' 1M.eand MUmiinWnaCeni Mof Cunwm Wb r-ba«er«Wart eSCMpen-
' radon, u provided for by Semloo 5771()0 of the Labor Coci for Nr pe f=m of the
wag for Nd permit is issued.
❑ I Noe W MU mafnuin Worhefs C.otpc okra Inauarsn. u rtgoirtd by Section
37W.f NeLb Colo, for the petfarmaua of Ne Wait f« which Nie 1-11 la I—"
My Waled. Camptuurl luwuta o WPdky number
Carrie.Policy No:
CERTIFICATE OF UEMMON FROM WORKERS
COMPENSATION INSURANCE
mrb mcdmMdi cot toc«nplctud Ifde Motor Is for one hutdrtd donan(SIM)
aloe.)
1 cenuN Jut or too Mrmmaxs of dr, wag For which Nd'conA u iuML I "I nm
evplay avp pcteon In NY mmrcr o b c b7«tb NCWrrtcn'.Compenudun
I�ws of nllfor m Dake
NOTICE TO APPLIC . affej making N� erdflrnc of Eumplian, you Nauk
bccmoe abjrct b Ne 's Competuatmn lRawof tlelah« Cndc. yw mon
r faMMNeomply wiN cb '(oriel«u «tltieprnnit .1001 he dsmN mmtcQ
CONSTRUCTION LENDING AGENCY
iii. inn spay f«Nc performacncM
Nn Bert uaPod
I boo
hafdm
1,On.
' the wait f« •hich the pemoit d Inued (S«. 7091, [W. CJ
son
IandYs Name
I «rdry dut I haus mad Ih'n applic W smc IbV Nc abuw mformatia. d
• cane. I aIi b comply wilt all sty W mwty on., W ^•r, laws nluin$ to
building Prnncamma, W eereby awhonim mptnu,rtrr ss a Nis city in enw ufnn the
.hove-mcntWed prop«ty for iupcNan pure x
(We) agme to ruim indemnify W keep harmless the City of CuMlino Vaiut
N dd City
raj Labilhim Judgmenu, coos tool cw whim may any w' ay same apron
r incotuegorcceofthegranting ofthim nuit
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REG TIONS_
Re -roofs
`'pe Of ROOF
" - We., .� , =- _ - � �
Sttunrt .f aavan« -.—
AIARDOUS KiX ALS DISCLOSURE
Will dic applinnl a fo uce budding occulounl pore «hntkk huadrus tori
by the CuMrbo, MurriciRl Coit. Duper 9.11 and do HcAt W Wmy
.Scaion25532(47 --
All roofs shall be inspected prior to any roofing material being installed.
❑�
�building
If s roof is installed without first obtaining an inspection, I agree to remove
Will ft applicw M (rvtUM Mutton are cqulpmw «dcv. w Ih
cmlt hvadncs air conumlwus a drfmN by Nc Bay Arta Mr QIWIIy Managcmcnt
all new materials for inspection.
o uk5
r�o
I I. read de by ni mwitirk Mince numtbrChap.695.(deCalifor-
N HmIN@Sdf yC.h,Secvou25505,25533W25534.1undmt Nn Ude hdking
don td curnuly have a u...m dw it u my rtaponsibilitY b naifY a T4unt of Ne
.:Ip bmuRIt on,, rwtniounnoors cerdre,r.r_G.�ny
Signature of Applicant Date
QN
ZtL
All roof coverings to be Class "B" or better L
_
Owwra ih«irsdegent'