04040054 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT
C� ILRAGrC1RTNF1RMnripLv
BUILDING ADDRESS: PERMIT NO. ,
NAVICO, INC 04040054
950 STEVENS, CANYON RD
I
PERMIT ISSUE DATE
OWNER'S NAME:
NAVICO. SANITARY N OL N0.
ONE:
BUILDING PERMIT INFO
ARCHITECIENGINEER: BLDG ELECT PLUMB MECH
Lm that I
ACTOWS -- - - --- -- -- - JpI)Description
1 Wreby affirm that 1 am fd licensed under provisions of Chapter 9(commencing
with Scares and
ofecDivision Sof NC BuainesenO Professions Code,and my licemc i.
in anus force and effort SEWER LATERALI or
S in License Clara Co g
Z' Dale Canaamm �/4 / -
Y ARCHITECTS DECLARATION T
Y I underaund my plans shell be used as public rccorN e/
7 eaU
u5 Licensed Pmfnsional ,ate
gym] Oat I am exempt
from
DECLARATION V�
1 hereby affirm that 11. exempt from Ne Comractofa License Law for the
00 fallowing meson.Permit
1 ](131.5,Business and Improve,
demolish.
Code:Any city or county
$ which mquima a permit re ematmct site,improve,h permit t m e pair ed tum um
prior uits issuance.also requires Nevisiosof for tachpermi's fIessignedsaamenl
that he is licensed pursuant m the pmviaion nl de COnuecmri License Lew(Chapter Sq.Ft.Floor Area Valuan ❑
(commencing with Sertian 7000)of Division 3 n1 the Business and Profession,Cod.).1 -
that W is exempt therefrom and the basis for the alleged ex mapllen.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant in a civil penalty of 3 rA Ig n�M'I 0 0 Occupancy Type
not more Nan five hundred dollars(5500} Z1a�O Y
0 1,ea owner of the pmpeny,or my employee with wages as their wh eampenss0on.
will do lhework,and Neawcmre is sal intended oroQered for sale(Sec.7044.Business Required Inspections
and Professions Code:The Courralun's License Law does not apply to an Owner of q P
property w ho builds or improve themon,end who does such work himsel f or through his
awn employee,provided that such improvements are net intended conflated formic.If,
however,the building or improvement is sold within ane year of completion,the owner-
builder will have the burden of proving Nat W did amt Wild or improve for purpose of
sale.)•
0 1,as owner Of the property,am exclusively contracting with licensed roe®cum to
convect the project(Sec.7044.Business and Professions Cade:)The Contractor's Li.
can=Law don not apply to an owner of property who Wills or improve themon,and
who contracts for such projects with a contractor(s)licensed pursuant dm Comnetoes
License law. -
Iamexe�nderSeaSea B&PCl rthia non
A�Dae
wen��S C MPE SA N DECIARC MPE SA N DECLARATION
1 hereby alum under penalty of perjury ane of the following declarations:
G I have and will maintain a CeNriceu of Consent to self-i.sumfwWorkeriCompen-
sation,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which Nis permit is Wood.
❑I have and will suinom Workers Compmtsadon Inman¢,as acquired by Section
3700 of me Labor Cade,for the performance of the work for which Nis permit is Issued.
My Waraces Compensation Insurance carter and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXFMP ION FROM WORKERS'
COMPENSATION INSURANCE
(The section need not be completed iftW permit is Intone hundred dollen(SI W)
or lea)
I certify Nat in Ne performance of Ne work for which aria permit Is issued.l shml not
employ any person in any manner an as to become subject to tW Workers'Conspersaflon
Law.of California Data
Applicant
NOTICE TO APPLICANT.If,after making this Ccatricam of Exemption,You should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.,0 foMwim cemply with such provision ter Nis permit shall be m
deeed revoked.
z y CONSTRUCTION LENDING AGENCY
'r+ I hereby affirm that Nen O ecomauctinn lending agency for the performance of
6:> the work fur which this permit Is issued(Sac.3097,Civ.C.)
W Q Undoes Name
D+ Lender's Addreas
U Q I certify that 1 have mad this application and sum that the above Information IS
W F' corrcet 1 agree m comply with pal city and county ordinances and suss laws minting to
0 V building corunw,tion,and hereby auNorim mpommouivn of this city an color upon the
W above-mon ioncd property for inspection purposes.
(We)agree 1.save,indemnify red keep harmless the City of Cupertino against
(0.A liabilities.judgments,costs and expenses which may in any way tame against midCity
V7 in consequence of the granting of this permit.
�7 APPLICANT UNDERS S AND WILL COMPLY WITH ALL ON-POINT Issued by:9 Date AA0
SOU GULATIO
Re-roofs
g' awrc of ApplicmVConuesmr
HA7ARDOUS MATERIALS DISCLOSURE Type of Roof
wall dtc applicam or future building aceupant store or handle harudom materiel
aadefined by tie Cupertino Municipal Code.Chaper 9.12.and the Health and Safety
ode,section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
0Yn Nu
Will the applicant or tutu building acsupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havamous air contaminants u donned by the Bay Arca Air Quality Management all new materials for inspection.
Dimrict?
0 Yes s'u
1 have mad the hvamama materials requirements underChapter6.95 of the Califer.
ria HcalN&Smcty Cedc.ScrOns 25505.25533 and 25534.1undcmund merit the building
does not currently hew a n4 Nat it is my responsibility m..mIy 1W aceupam of de
requite whichromImtpdorro' ccofaCenifestrof up Signature of Applicant Date
own authoriaedagcnl A Dam` All roof coverings to be Class"B"or better
Community Development
.' 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
9UPEkTINO
Building Department
JOB ADDRESS iDgS—O 54-2✓en5 Can\tvn PE #
OWNER'S N A//)09D TnC• PHO — 41—os S
GENERAL CONTRACTOR: Na✓�co, --rAc. FAX # yp 7 I —d,fb
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
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
'Plumbing JutiO n Elp
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ cb r Signature Date
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
CUPEI�TINO PERMIT APPLICATION FORM
APN # 3 5& -OI — O q l Date: d �)
Building Address: 10q5-0 S+eVen5 Ca ,n -R-d .
0
Owner's Name: I —cssS h / Phone#:4Off—7,{
��l a1/I�� -L`n C.
Contractor: . / C Phone: 7
4( —oS gs-- License#:
Contact: $,/���10 �a��C� Phone: 74 — Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb [A
Job Description: Sev,�PX'
Residential g( Commercial ❑
Cost of Project:*
Qty. if
A lic 1 Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
31