04040055 CITY OF CUPERTWO - ,kCO UI��X �IT,L�VI�AT-10M, .. . -. . .-- ...
BUILDING DIVISION PERMIT rx .....Ft,w"i- > Yc5'••, ow '
BU
A ILDINGADORESS: NAVICO, INC PERMIT NO.O4O4OOS5 '
OW NER'S NAME: PERMIT ISSUE DATE
NAV SANITARY OL NO.
ONE:
ARCHITECTIENGINEER: BUILDING PERMIT INFO
eLDG� ELECT I� PLUMB O mECH�
A0z LICENSED CONTRACTOR'S DECLARATION - -- - - - -^- - -- —""---- - -
1 bcrtby affina that 1 am licensed under prnviaions of Chapter 9(commenting JOb DESCTIPGOn
with Section Ill W)M Division 3ofMa Business and Prods inns Code.and my licenm is
`a orN infmlrn=and effect. SEWER LATERAL FU A LPI-
Z el z- License Clue Lm g
n t-� Dau contracmr,
ARCHITECTS DECLARATION ASR 2004
1 undemund my plans shall be used u public rtwrtls
hi U
''tua Licensed Professional
OWNER-BUILDER DECLARATION A�
<� 1 hereby.(Sec that 11. exempt from dx:Conio nCo License Law for my BUILDING
i a o following moron.(Section]1131.5.Business and improve.
tins demolish,m Any city oe county
u�$ which requires a Permit tar teres Me alar,impose,h Permittor repair any statement
prior m its issuance,atm requires Ne applicant for ouch permit m fide a signed Chapw,
!'fie thatbeincingwi Purslion7 heofDivionsn.fiM til n,.s diflsion&Cpter9 Sq.F[.Floor Area Valuate
s�o
m $ 'at No is ammii therein rn and of basison 3 treat B ed ass and on.An ionsCMe)of
�.. Net he is exempt therefrom and dte buts for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects dee applicant to a civil penalty of 3 WTI,NUI] erp O Occupancy Type
not more than five hundred dollars(SSW).
❑I,uownerofthepmpeny,mmyemployceswithwwgesuthelrsolcwmpenudon,
will do the work and thestmcture isaotrntendcd aro@and fmna7e(Sec.71144,Butlmas t
load Professions Codc:The Coursomes License law docs not apply to an owner of Required Inspections
property,who builds ter impmvu themon,and who does such work himml f w Nmugh his
own employees,pmvided that such improvements are notintenaed oroRered forsak,if,
Will 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
sal
rl.as owner of the property.am exclusively contracting with licensed wn=wm to
conslron the project(Sec.7044,Business and Pmfcaudons Code)The Contractors U.
cave law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a Criminal lianed pursuant to the Control
a Law.
I am mumnit an&,SOl Bi PCfor thi moan
Owner _ I\ nAlrsr� Dear
WORKEASrC PEN ATINATI0
1 hereby affirm under pemlty of perjury am of the following decimations:
1 have and will maintain a Conifiam ofC.maom m self-insure for WorkersCompcn-
,man,u provided for by Selden 3700 of the labor Code,for the performance of the
work for which This Permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u required by Sol
3700 of Ne labor Code.for the performance of the work for which this permit Is issued.
My Workers Compensation Inso anw carrier and Policy number am:
Coal Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thismnion need rimbecompleud if the permit Is forms,hundred dollars(SIU)
or less.)
1 certify Nae in%e peffmmmen of the work for which this permit is issued.I shall not
employ any person in any manner so as m become sl to the Workers Compcnsatrun
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making Nis CcniOcale of Exemption,you should
become subject in Ne Workers Compensation previsions of Ne labor Code,you must
OZ forthwith Car ly with such provisions or this Permit shall be dcemod revoked.
„zO CONSTRUCTION LENDING AGENCY
[-i I hereby effort that More is a consttvmion lending agency Car the petionomen of
Cli> the work for which this permit is issued(Sec.309E Civ.C.)
WQ Lenders Name
e, Z Lender's Address
UR 1 certify that 1 have mad this application and smile that the about Information is
LT. F Correct.I agree he comply with all city and county ordinal and sum laws relating W '
DU building construction,and hereby anthorime repremmutives of this city It enter open the
4 above-memioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupcnino against
F v) Imbilltles,judgments.cosu and expenses which may in any way menial mid City
U Z in consequence of the granting of this permit.
APPLICANT UNDERST6HPS AND WILL CO PLY WITH ALL NON-POINT Issued by: Date
SOU GULATION
Re-roofs
ap1�luA,CFApqrIicmMCormmtor IDa
HAZARDOUS MATERIALS DISC LO Type of Roof
Will the applicant or future building occupant nom or handle hevallous material
as defined by the Cupertino Municipal Code,Chapter 9.111,and the Health and Safety
Adoccol SimonCy.zss3z(a1? All roofs shall be inspected prior to any roofing material being installed.
❑Yu g�Nu
Will the applicant or fuull building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Fail hazardous it contaminants u defined by the Bay Area Air Quality Management all new materials for Inspection.
District?
❑Yes
1 have mad Ne harardws materials romiremcnts under Chapter 6.95 of the Califm-
hisHoalth&Safety Code,SCcdou 25505,25533 and]5534.1 undersand dam ifthe Wilding
does no unentI have a tcn Nat it is my responsibility m notify thc occupant of Ne
rcyvi mnslbe ammivaanL racmtinLate foo enPane Signature of Applicant Date
Owner or ammnriaca seem All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
i Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOBADDRESS- O q S�even S 1� 20�/ PERMIT#Od
OWNER'S NAME: Ravicae—IAC-- PHONE # 41 05",S'S
GENERAL CONTRACTOR: NamNcoFAX # 74 t _05'4,
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Aft Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing a
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINOOf
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN# :35 6 - o I _ o 4 Date:
Building Address: 1.9,T 54e✓ey1 S OAA joy) pe .
Owner's Name: !�(a✓i _�C Phone #: 7-{ ( -0S-S S...
Contractor: � Phone: License#:a✓tC�, 2nC• 741 -os-ss'.
Contact:
6'or� Phone:\ s Cupertino Business License#:
'8 ►�0.�/i �` 7y l-os S
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 15\
Job Description:
Residential Commercial ❑
Cost of Project:
•
Qty. if
A lica Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit IssuanceJBUI
MBING
BPREPIPE Re i e of FixturesMBING
BPERMFEE Bldg. Permit Fees LDING
BPFIXTURE Pbl . Fixture MBINGBPWSVCS Main Water ServiceMBINGBPSEWER Sewers MBINGBPSEWAGE Sewa a Dis osal MBINGBUSLIC Business License LDING
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