03090233 (2) - "CITY OF CUPERTINO
BUILDING DIVISION PERMIT COTRAtT0R`INF0RMA�IQN
,.. .
I BUILDING ADDRESS: PERMIT N0.03090233
OWNER'S NAME: - PERMIT ISSUE DATE
NAVI 911.12 Q
NE: SANITARY N0. CONTROL NO.
4og) 741 -oSSs
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACT'OR'S DECLARATION
u❑ 11 corm that I i m licensed undo,provisions of Chapter 9(commeneing Job Description pp��ss
,x6U with SCCtiont/X%1) fl)isiakm311finesusine. rad Profcssinne Codc,and myliccnx is �'�^LE
< in mummeakJFfc�"� p TEMP POWER POLE N
i Lice se Tai,(.p—�1.�7—���Lic.N
imp DatQ�✓_ Cont,C cam'=m r' a CONTRACTOR: NAVICO, INC OCT 0� 12003
¢Q —''�Yr ARCHITECI'SD ATION
i 2� 1 understand my plans shall he used as public records
j6D
°a.0,�„ Licensed Pmfcsaionel BUILDING OWNER-BUILDER DECLARATION �UILDINMt
Qf 1 hereby reaso .(firm that I oat exempt from the Gonlmeleo e:Any c Law for the - tlrlM
.pO fallowingreason(Section]f13L5.Businessand improve.
Code:Any can orcounty
mehou
5 which requires Issuance.permit reconstruct,spec,i t forsu demolish,ore pair any strumum
.zi priortnslits ensedponlso rmatto res theapplicantof dire Cohpermittoicense ned Low
w(Chwmeat
xx<
(commthathe encing
with
n7 h)(ifDivision3oheConwnessaniccnsessions opmr9 Sq. F[. Floor Area Valuatio�g500-
2F$ (cat he
xempt Seminars and rar basis
n3 ofthe
egedcssontl Professions
Cndc)ser
.. Net he is exempt Nemfrom and the breis for the alleged exemption.Any violation of scs e
Section 7031.5 by any applicant for a permit subjects Ne applicant to a Civil penalty of 3AeN Milibef O0 Occupancy Type
not more than five hundred dollars(2500).
❑1,as owner of the property,or my employees with wages m their sole compensation,
will do On work end the incline is not intended or offered for sale(See. Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of 103 — UFER q
property who builds or improwo
harpoons thereon.end who does such rk himself or through his
own employees,provided that such imprommenu we not intended or offered for sale If. 304 — ROUGH ELECTRICAL
however,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 on.of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed emissions to
construct the pmjCct(Sec.7044,0asinces and Professions Code:)The Contractors Li.
come law does not apply to an owner of property who builds or improves gr moo,and
who contracts for such projects with a Contortions)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. ,B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am or Ne following declarations:
I have and will maintain a Cenificam of Consent to self-insure for Worker's Compere
137M
on,as provided for by Section 37W of Ne Labor Code,for the performance of one
k for which this permit is issued. i
1 have and will maintain Worker's Compensation insurance,m required by Section
of Ne Labor Code,for Ne performance ofNe work for which Nis permit is issued.
Worker Com emight, Insurance caner rad Policyynuy 6^obsarr mmr: p,� 'a..`,er. �.j�(�JI/pCliey o k;4 aL2&5C�3
CERTIFICAT•OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomplcted true permit is!moot hundred dnllars(21(1(1
or leas.)
I cenify Not in the praf emo nce of the work for which this permit is issued.l shall not
employ any person in any manner an as in Become subject to the Workcri Compensation
Laws of California.Dow
Applicant '
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Com remotion provisions of the Labor Cndc,you muse
�Q forthwith comply with such provisions or Nis permit shall be deemed revoked.
ti0 CONSTRUCf10N LENDING AGENCY
I hereby affirm that there is a constrectinn lending agency rat the performance of
Y'> the work for which this pemtit is issued(SCC.3097,Civ.C.)
Q Lenders Name _
z Leadcr's Address
;J Q I minify that I have read this application and sore Net Ne above information is
YF correct.I agree to comply with all city and county ordinances and state laws misting to
�O building construction,and hereby authorim mpmsenmives of this city to enter upon the
W about-mentioned property for imngthen purposes.
(WO)agate to save,indemnify and keep homeless the City or Cupertino against
~1�/] IIab1IGes.f VdgmeaL{,LOSld and CFpCnSCa WM1ICh m4y In any Wey scathe Bgaln51 a91d Cl ty
J7 in consequence of the granting of this permit.
r7• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SQURCE REGULATI a
AfY/_'7 j fais,-yi/
Re-roofs
Signature or ApplummuContractor to
,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal,Code.Chapter 9.11,and the Hcalth and Safety
Code,Section 25532(.)' we All roofs shall be inspected prior to any roofing material being installed.
rYcs ,
01 the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hasardoos oir conmminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
❑Ycs �L
I have mad the hazardous materials requirements under Chapter 6.95 of Nc Califor.
nia Health&Safety Code.Sections M505,25533 and 25534.1 understand mat if Ne building _
dors not currently have a tenant.Nm itrespamibility w no y the occupant of Ne
rqulrcuum vhkhmup ctptioluis aneeoracemrcam Ocap y.� Signature of Applicant Date -
Oa'or awhori'rcd aFcm part All roof coverings to be Class"B" or better
cr
CITY OF CUPERTINO
TEMP POWER J3 � �j°o z
CUPEkTINO PERMIT APPLICATION FORM
W tt
APN #
Building Address: S �z✓P v\S_
�C> 915l
Owner's Name: It4G VIS J N G Phone t+v0741 03S5^
Contractor: r� r'� C Phone: License#:
Contact: Phone: -74 I _ S Cupertino Business License#:
Build' Permit Info:
Ele
Job Desc iption:
r
Residential { Comm ' cial
Cost ofProjeel•
Qty. .
A plitkie Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING