03100096CITY OF CUPER'1'INO'v°�°='�@,-'°'+s'��
BUILDING DIVISION PEMI
RT
�yyCoN 'Q- QR IaNFORMATION
BUILDING ADDRESS:
994 ST-9VENG GANYGN RD.
PERMIT NO.03100096 3100096
'R'S NAME:
FERMITISSURDATE
NE:
SANITARY CONTROL NO.
ARCHI3ECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MPRH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
OCSCTIp
Ib Description
1 hereby AM,. that 1 am licensed under pmvisions of Chapter 9 (commencing
with Scccn 3 of the Busiticss end Prufcuiom Cotic. end my license is
ecDivision
in full force anerad effect.
DEMO r
License Clan Lc. /
Dam
CONTRACTOR: NAVICO INC. (#24836)
TSDECL
ARCHITECTS DECLARATION
r Q /
Iunderstand myplansshall he .,to as public rocnrds
`3 )
Licensed Professional
OWNER-BUILDER DECLARATION
03
I hWools,al'Orm that 1 em exempt fru. the Contnctofs License Law far the
following means. (Section 7001.3. Business and Professions Code: Any city or county
Which myuires a permit to cmnmmcL alcor, inu rnw, demolish, er repair any street..
prior in its issuance, also mquiros the epplicam for such permit m file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuat og 000.
(commencing with Section 7000) of Division 3 of the Business and Pmfcssions Code) or
i
Nn be, is e.empt thertfmm and the basis for the alleged esempton. Any violate. of
3 � ygpger00
Occupancy Type
Section 7031.5 by any Applicant for a permit subjects the applcam I... wit penalty of
not mart than five hundred dollars (5500).
❑ 1, as owner of the property, or my employees with wages as their $ole compensation,
Required Inspections
will do Ne work, and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Codc: The Cornmemea License Lew docs not apply to an owner of
property who builds or improves thereon, and who does such work himself or u1i his
704 - DEMO
Own employees, provided Nm such improvements art not intended oroRered fertile. If.
however, Ne building or improvement is mid within one Scar of completion. Ne ownrn
builder will ban the burden of proving that he did not build or improve for purpose of
_
sale.).
1, es owner of she properly, am mcimlinly contracting Willi c.mractors t.
construct the project (See. 7044, Business and Profcsvons COde:)no Comncmr's Li.
Geese law does not apply in an owner of property who builds or Improves Menton, and.
who contracts for such projects with a con ramor(s) licensed pursuant to the Contractor's
License law.
[?I un exempt under See .B& P C for this meson
r
�L�iADTION1U
WORKER'S COMPENSATION DE
I herchy shine under penalty of perjury A. of she following declarations:
"
I have and will maintain a Cenif¢am of Consent to self insum for Worker's Compcm
urian, m provided for by Section 37M of the labor Code, for Me performance of the
work for which this Permit is issued.
❑ 1 haw and will maintain Worker'& Compensation Insurance, As Attuned by Section
37W of Me labor Code, for Me Performance of Me work for which this permit is issued.
My Workers Compensation Insurance anicr and Policy number art:
Cartier. Policy NO:
,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mdu section need not Wrompleted If the Permit is for one hundred dollars (nihil)
in Mss.)
I certify Mat in the perinrmanec of the work for which this Permit is issued, I shall not
:.Play. yfirs� iqany rearipiri sato c0 Aso b'cctmlhe Workers'Compcmadon
Lew. of CJifornla,mam
Apid At ''ff�3 A '
N��.,•a•�y. a�'.0 AML CANNT: IL after ratingthisCertifc le of Endolu on, you should
berpye subject to the Worker's Compensation previsions of Me Lather Cotic, you most
fo th comply with such previsions or this permit hall he deemed revaked.
CONSTRUCTION LENDING AGENCY
I hereby a(f rm Met there is construction lending agency tat he perhamence of
Me work for which this palm it is issued (Sec. 3097, Civ. C.)
Lender's Nam.
lender's Addmu
I cenify Mu 1 haw read this application and sum that Me above information is
correct. l agree to comply With ell city and county ordinances and sum laws relating to
building convection, and hereby auMarim repmsentatiwa of MIS 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 espcnses which may In any way seem= against mid City
in consequence of Me grannng of this Permit.
��
1f
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by:. Date �7/,27
SOURCE GULATION . ^ /
Re-roofs
Type of Roof
�I (6-
nature of APphcauVCmhacmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will Me applicant or future building Occupant store or handle huWous material
As defined by Me Cupertino Municipal Code. Chapter 9.13. and the Health and Safety
. Searles 255324)7 1"
All roofs shall be inspected prior to any roofing material being installed. "
❑Yes CD No -
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future buildingacup rnonequipmentordeviceswhich
It hamrdous air condominium As defined by Me Bay Area Air Quality Management
all new materials for inspection.
urict?
❑Yes MINA
I have mail the h ranhon materials sequiremcnu under Chapter 6, 95 of the Califor.
nia Health& Safety Code, Sections 25505, 25533 and 8534.1 unt edur ad Mat if the building
does not etecntly hew a mnanti Mat it is my msponsthility m todl'y she occupant of Me
roqui;m wmcn asst met pooruiss annCertificate ofCtcr,�sSigna[ureofApplicant
Date
All roof coverings to be Class "B" or better
wncr ser authmimcd agent pate
00
CUPEftTINO
CITY OF CUPERTIN
DEMO, ; G )
PERMIT APPLICATION FORM
APN #3 J& y V l—
0 4 9
BUILIDNG
Date: q I o
Building Address:
BSEISMICOM
X095 S
ekns CAr ar) 2cj
Owner's Name:
z�,c he r
,,fu ✓id
BSEISMICRE
Phone
741 —o s ss -
Contractor:.
N a v j (- c))
License #:
1- &9 2- 570
Contact:
(�iio�
t
Iv��vl�
Plan Check Fee
Phone
Applicant/Contractor:
P4��1C�
Building Permit Info:
Bldg
Elect Plumb
Mech
Job Description:
Residential:
Siris -F,.> rn l "
Commercial:
Sq.Ft. Floor Area:j400
�Q �,—
J,,"
$/Sq.Ft.: �,---_
9
BUSLIC
Architect/Engineer:
BUILIDNG
Val tion:
Type of Construction:
�+
O cupancy Group:
Qty
if
Ap c �e
Fee ID
Fee Description
Fee Group
BPERMFEE
Bldg Permit Fees
BUILIDNG
BSEISMICOM
Seismic Commercial
BUILIDNG
BSEISMICRE
Seismic Residential
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG
tU P:zU
taa
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Lu
aU
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C
CITY OF CUPERTINO
BUILDING DIVISION PERM]
CONTRACTOR INFORMA7 V.
BUILDING ADDRESS:
PERMIT NO.
03100096
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY O. CONTROLNo
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code. and my license is
in full force and effect.
DEMO
License ClassLic. p
Date contractor
CONTRACTOR: NAV I CO/ INC. (#24836)
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Secrion 7031.5. Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior n) its issuance. also requires the applicant forsuch Permit to file a.signed statement
Sq. Ft. Floor Area
Valuatog
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
0 0 0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3MbI y1zJl�er 0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more than five hundred dollars (5500).
❑ 1. as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
ns
q p
property who builds or improves thereon, and who docs such work himself or through his
704 - DEMO
own employees, provided that such improvements arc not intended or offered for sale. If.
however, the building or improvement issold 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 docs 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.
Q'l am exempt under Sec. , B & P C for this reason
) /
Owner '.l� t I\ �^"/+;^✓ t�A _J�Date
WORKER'S COMPENSATION DECIL ATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain aCcrtifieatc of Consent to self -insure for Worker'sCumpen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 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 arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION 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 t any mannccko as to bcco c subject to the Workers' Compensation
Laws of Califor hate
Applicant-��
NO O A IfCANT: If, after making this Certificate of Exemption, you should
bec, subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construetinn lending agency for the performance or
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building consuuction. and hereby authorise representatives of this city to enter upon the
ahovc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, Judgments, costs and expenses which may many way accrue against said City
in consequence of the granting of this permit.
C>
APPLICANT UNDERSTANDS AND WILL COMPLY WITH .ALL NON -POINT
Issued by: Date
S OU RCE..�GU LATIONS.\
III
Re -roofs
Type of Roof
4 �.I\ r'✓ C
9 naturcofApplicant/Comractor Date'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store nr handle hasarduus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
❑Yes vd Nu
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by (he Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes R`No
I have read the hasarduus mase: rials requirements under Cha Pic r 6.95 of the Califor-
nia Hca lth & Safcty Code, Sections 25505.25533 and 25534. I understand that if the huiIding
docs not currently havc_A tenant, that it is my responsibility to nouly the occupant of the
requirements which must be met prior to issu ee of a Certifrcatc of Occu aney, L
�il-
Signature of Applicant Date
"��.�-�) i <.�,�,,'' �i3
,
All roof coverings to be Class "B" or better
Owner
or authorized agent Date