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04040056 (2) CITYOF CUPERTINO BHam vc DIVISIONPERMIT TNF�IRMATIU s ,�,a; v BUILDING ADDRESS: PERMIT NO. , NAVICO, INC 04040056 ' OWNER'S NAME: PERMIT ISSUE DATE ft ONE: SANITARY OL N0. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH cl o 0 0 LOO LICENSED CONTRACTOR'S DECLARATION IOb Description i I fairly affirm that 1 am lienaed under provisions of Chapter 9(commencing n< wide Section 7")nfDivism.Softhe B.A.ss and Famous...Codo,tudmylk.assis < in full fort md.lfact. �y t,MZ Lod&aCIAA Lk.a SEWER LATERAL �"6 ia��m�1J n 0 Dek Contractor O ARCHITECTS DECLARATION I i understand my plans shall m used As public records Oa, APR 12A, 2004 C Licensed Professional OWNER-BUILDER DECLARATION 1 hereby amrm that I am exempt from the Contractor's License law far the BUILDING Res O following mason(Sudan 703 1.5,Business and Professions Cade:Any city or county 21 which requires a permit to commoci,altar,improve,demolish,or repair any stetted, FZ< prio,1.its issumec,Am rrquims the applicant fdrsuch pcaral in file a signed statement £ O that he islienkdpirmanttoamprovisions af0.CoolrmtodLicense Law(Chapkr9 Sq.Ft.Floor Area Valuati ❑ y�$ (commencing with Section 7000)of Division 3 ofthe Bosinessand Professions Cade)or , that he Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3.A,B7S-i�6....i.er Q Q Occupancy Type not mate Nan five hundred dollars($500). .'ni V t bed§ I,as manes afthe propcny,army employees with wages as their able compensation, willda IbmworL end thnsna..is notinknded or oifemd forsale(Sec.7W.Bminns and Profusions Cade:The Commander License Law dors at apply do an owner of Required Inspections property who buiidaartmprovea thereon,and whodoeaauchworkhimselforthmugh his ownemployces,provided Nnauch improvements are notinknded oroffered ficamd.if, however,the building or improvement is sold within atm year of completion,Ne Owner. builder will have the burden of proving Wt he did not Wild or Improve for purpose of sale.). [11,as owner of the property,am exclusively contracting with licensed contrmtora to construct the project(Sec.7004,Business and Promotions Code:)The Contractor's Li. cense Law does not apply man owner of property who Wilds or improvra thereon.and, who contracts for such Projects with a comonclai licensed pursuant to the ContrsmrS ns Law. 55i�g� B&PC orChiam�on Dek `I INS TION DE ATION �/ /erjury ark of owing declarations: I have and will maintain aCenfftcak of Camera(to self-mi um for WorkerhCompen- 7C313IM tion,a provided for by Section 3700 of the labor Code,for Ne Permanence of dee rk for which this permit is Wood. I have and will maintain Worker's Compensation Insurance,n tvquimd by Section of Ne Labor Code.for the performance of Ne work for which this permit is issued. y Workers Compensation Insumme carrier and Policy number art: rrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not W camplcued film permit is foram hundred dollars($100) II loss.) 1 certify Nat in the performance of the work for which this permit is issued,1 shall not employ any permn in any mannerso as k become subject to ted Worla n'Compemadon Laws of California.Data Applicant NOTICE TO APPLICANT:If,after making this C.nifcak of Exemption,you should become subject to the Worker's Compensation previsions of dm labor Code,you must .JO forthwith comply with such Towisians or this permit shall be deemed revoked. „zy rte~. CONSTRUCTION LENDING AGENCY (ti I hereby affirm that awns is aconstoctinn lending agency for the perfurmm¢or N. > murk for which this permit is issued(Sec.J097,Civ.C Le J D, 0 Lender's Namc .7 z Lender's Address V Q T certify Nat I have tend this application and sok Nat Nc above information is [I.!+ corccl I agree m wmply with all city and county ordinances and slow laws relating to 0 CSJ' bung construction,and hereby authorise mpmunutives of this city m enter upon Ne above-mentioned property for inspection purposes. F (We)agree to save,indemnify and keep harmless the City of Cupertino against fA liabilities,judgments,costs and expenses which may in my way accrue against mid City `(/�Jl' fJ 7 in consequence of the flooding of this permit. G APPLICANT UNDER DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date URCE ULATI NS. �/ �/J /i6�0 �� Ls!A,11 / /A"� Re-roofs nature of ApplicmuContomw r I Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future building Occup rat store or handle hrnrdous material x as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety co!1.,s.aY.zss3z(a>? All roofs shall be inspected prior to any roofing material being installed. ❑Yrs �Nu Will the applicant or row Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit ha annus air mntarromms ss defined by the Bay Area Air Quality Management all new materials for inspection. District? L ' ❑Yrs Alk. - I have reed Ne hvardaus matarials requirements under Chapter 6.95 of the Califm- old Health&Safety Code,Sections 5505,25533 and 25534.1 undenwnd thin if the building docs not curmntly hove a knot Nat it is my rnponsibiiity to nod fy de medical of the mquimm isswhichmust prionoissian ofaC.nilicate46 fq o timnpy. Signature of Applicant Date ow rauthonxcdagcin Da All roof coverings to be Class"B"or better F Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 aclor Fax(408)777-3333 SUPERTINO Building Department JOB ADDRESS: Sdi(e✓en S ear )v n gd. PERMIT# OWNER'S NAME: qy)f � ©, lC. U PHONE # 74 — 0 SS GENERAL CONTRACTOR: ,vr?Q2i ^ , FAX # 7 —OV6 7 I am not using any subcontractors: " Signature Date Please check applicable subcontractors and complete the followin 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile I M . k C14 Arl o Owner/Contractor Signature date CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN# 35 & ` of , 043 Date: Building Address: 1© Qs¢ 5�e✓e✓IS Carlen Owner's Name: N (a v� -1-,(\ C Phone#: Contractor: Not Vi CO) -4,t\C• Phone: -74-1_osss- License#: Contact: ©n ^ /��1 Phone: 74 ) _©SS r Cupertino Business License#: Building Permit Info: 'V Bldg ❑ Elect ❑ Plumb Job Description: Residential Commercial ❑ Cost of Project: �i000. • Qty. if A li e 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