B-2017-2027 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2027
20687 CRAIG CT CUPERTINO,CA 95014-2912(359 15 019) DOMUS
CONSTRUCTION&
DESIGN INC
SACRAMENTO,CA
95826
OWNER'SNAME:LE VIET VAN THIEN AND NGUYEN TRANG THUY THI DATE ISSUED:07/09/2018
OWNER'S PHONE: PHONE NO:(916)381-7500
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic.#932059
Contractor DOMUS CONSTRUCTION&DESIGN INC Date 04/30/2019 X BLDG—ELECT—PLUMB
MECH X RESIDENTIAL COMMERCIAL
I.hereby affirm that I am licensed under the provisions m Chapter 9(commencing
with Seaton 7000)of Division 3 of the Business&Professions Code and that my
license Is in full force and effect. JOB DESCRIPTION:
SINGLE STORY-REPAIR DAMAGE TO GARAGE(439 SF),REPAIR
I hereby affirm under penalty ofperjnry one of the following two declarations: ROOF(8 SQ),(N)WINDOWS(3),REPLACE DAMAGED DRYWALL
r, 1 have and will maintain a certificate of consent to self.insure for Worker's (475 SF);ADD ROOM(349 SF);ADD 75 AMP SUB-PANEL;
Compensation,as provided for by Section 3700 o£the Labor Code,for the PROPOSED REAR TRELLIS
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for The performance of the work for which this
permit is issued Sq.Ft Floor Area: Valuation:$163000.00
APPLICANT CERTIFICA'f10N
I certify that I have read this application and state that the above ppN Number: Occupancy information is correct.I agree to comply with all city and county ordinances Type:
and state laws relating to building construction,and hereby authorize 359 15 019 R-3(Custom)
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations/per the Cu ertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatu e /(, Date 07/09!2018 Issued by:Jasmine Archbold
Date:07/09/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
n. I,as owner of the property,or my employees with wages as their sole installed without first obtaining au inspection,I agree to remove all new materials for
compensation,will do the work,and the stmeture is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z 1,as owner ofthe property,am exclusively contracting with licensed Signature ofApplicenc
contractors to construct the project(Sec.7044,Business&Professions Code). Date:07/09/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,w provided for by Section 3700 of the Labor Code,for the
Performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
Pared t is issued. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
s. I certify that in the performance of the workfor which this permit is issued,I health&Safety Code,Section 25532(a)should I store or handle hazardous
shall nofemploy any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
atr contaminants as defined by the Bay Area All Quality Management District I
Worker's Compensation laws of Californis.If,after making this certificate of will maintain compliance with the Cupertino Mtin(cipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,255$,and 25534.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Data:07/09/2018
certify that I have read this application and state that the above Information is CONS'1'RUC'1'lON LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec,3097,Civ C•)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save Indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 07/09/2018 Licensed