04030054 CITY OF CUPERTINO
BUILDING DIVISION PERMIT IYCONTRAGTO'R ORMATIQN '
BUILDING ADDRESS: NAVICO, INC PER""ND04030054
10950 STEVENS CANYON RD
OWNER'S NAME: PERM"ISSUEDATE
NAVICO, INC 20480 BLAUER DR. A 06/18/2004
E:
SANITARY NO. CONTROL NO.
(408) 741-0555
ARCHITEC(ENGINEER: BUILDING PERM IT INFO
BLDG ELECT PLUMB MECH
u O O LICENSED CONIRACIOR'S DECLARATION
m❑ 1 hereby affirm that I nn limn¢d under provisions or Chapter 9(commencing Job Description
iW wile Section7l00)of Divisian 3ofthc Butlrcssand Prefossions Codc.md my Hem.is
�« imm�forceandeff«L SFDW-2—STORY (3749 SQ. FT. LIVING SPACE)
n Ll Z Licenx ClassLie.Jr
zrw Date Convutor GARAGE 641 SQ FT
ARCHITECTS DECLARATION
I< 1 understand my plans shall be mood as public records
�LeU
o N Licensed Professional
S OWNER-BUILDER DECLARATION
<F 1 hereby affirm that 1 rem exempt from Ne Convector's License Law for the
o O following reason.(Section 7131.5.Business and Professions Code:Any city or County
29 which requites a permit stn construct,aline improve,demuliah,or aped,my srumum
HZsnissuance.
prior its also requires she applicant for such Permit no file a signed statement
moss he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area VaI,31StRA860
Moo (commencing wish Section 70M)of Division 3 of the Business and Professions Code)or
y
that he is...pt therefrom and the basis for the alleged esareption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to•civil penalty of APN Number Occupancy Type
nut mars than five hundred doffs;45M). 35601049 . 00
P y yP
❑Laownerof the pro pony,mmyotimenees wrshwageaassheirmld earepenaoon,
will Pt Ncwons ands, he Contisrum's Lndedorowred(one'spply he an Business
and property
bu Code The veld amon,License Law dors or apply r an owner of Required Inspect,
own employ b,provided thav"thimprovndwho dcesemhwurkhimuRarshmdgb his
ownemploy=,th Wiping or thatmenrreprmemmoare not ear ofAmoR"ed for owncy-
however,the fireprovarroon mid withinm yea,ofmprovefrNeQuer-
ZZLI
builder will have she burden of proving Our he did not Wild or improve far purpose of
UAI
sale.).
es own"or the property,me delusively contacting with licensed conlrmtors to APR
ED
conssmct the pmjecl(Sec.7044,Rosiness and Pmf"siom Cade:)no Contnemrt Li- U lJ
came low docs not applyje an awn"of property who Wilds nr improv thereon,and,
who consmcu for such projects with a contmttos(s)licensed pursam w tee ConvactoYs {/
wiccnse Law.
emps under S". ,B&PCT chis n
Owner Data �®
WOR E ON DECLARATION+;� ®�(/ l`9m.M
1 hereby affirm under Penalty of perjury one of the following declamations: l/
1 have and will maintain a Cenilmm of Consent to salt-insure for Worker'sCompcn.
sation,as provided for by Section 3700 of the labor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Wmk"'s Compensation Insurance.m oxidized by Section
3700 of due LOW,Code.far the perfarmana of the work for which this p.it is issued.
My Worker's Compensation Insurance arrier and Policy number art:
Cartier, Policy No.: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbu section nerd not be completed if the permit is for one hundred Corona;(SIM)
Icss.)
1 certify that in the performance of Ne work for which this Permit is issued.I shall not
employ any person in any mannerm as to became subject to she Workers Compensation ^
Laws of California.Dec
Applicant
NOTICE TO APPLICANT:IL after making this Cenilam of Exemption,you should
become Subic"to the Worker's Compensation previsions of the labor Cade,you must
.,O forthwith comply with such provisions or this Permit shall be decreed mvelmd.
Z" CONMUCTION LENDING AGENCY
[-i.�. I hereby affirm that there is a cornu neion lending agency for the Performance of
ce the work for which Nu permit uhundred(Sm.3097,Co.C.)
CQ tondo's Name
=z Lender's Address
U Q I Certify that I love and this application and state Nat the aWve information is
^� correct.I agree to comply with all city and county ordinances and slam laws reining to
V Wilding Construction.and hereby selfsame mprenmiver of this city to corer upon the
W imbilireenuanWpropeny for i expenses
purpowhich ex
y (We)agree m arc.indemnity and keep harmless the City of Cupertino against
h in Color and eapcns"which may in any way urnre vgaitw sold City
V A APPLICANT
of the Granting of this permit.
APPLICANT UN NDS AND WIIJ.COMPLY WITH ALL NON-POINT Issued by: e
SOU EREGULATION . ,�l/V-ily/
Yds
$IBnaldrC orApplicaMCons cmr� 'I pm I Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant dr lmum Wilding occupant nom or handle haratdous rommal
ss cotton, by the Cupertino Municipal Code,Chapter 9.12,and Inc Hcalth and Safety
ode Section 25532(.)?
pr N�Na All roofs shall be inspected prior to any roofing material being installed.
Will thea beam or future building sad of tote m If a roof is installed without first obtaining an inspection,I agree to remove
nn s w a treat lit deices rumen g P
ala harardnus air conominanu as delncd by the Bay Ata Air Quality Management all new materials for inspection.
UWICI?
❑Yes �Na
I have read the hzramtmsmnen-la regmiomema under Coapt r 6.95 of tate Callror-
ria Health&Safety Code.Seeuoav25505,35533 and 25534.1 understand thaif ore Wiling
Jonot
" c a¢nal.Nat it¢mY nsihility to notify the,asupant of the
,a month whlanm met urtoiam art.cenifia¢ar cep Signature of Applicant Date
All roof coverin s to be Class "B"or better
Owner or ausharirc agent Dam g